37010 MedPerform Low Formulary July 2017 FINAL · 37010 MedPerform Low Formulary – July 2017 iii Depending upon a member’s specific benefit parameters, the following topics may

37010 MedPerform Low Formulary – July 2017 i

MedPerform Low Formulary July 2017

Foreword This document represents the efforts of the MedImpact Healthcare Systems Pharmacy and Therapeutics (P & T) and Formulary Committees to provide physicians and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. A structured approach to the drug selection process is essential in ensuring continuing patient access to rational drug therapies. The ultimate goal of the MedPerform Formulary is to provide a process and framework to support the dynamic evolution of this document to guide prescribing decisions that reflect the most current clinical consensus associated with drug therapy decisions. This is accomplished through the auspices of the MedImpact P & T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. To accommodate changes to this document, updates are made accessible as necessary. As you use this Formulary, you are encouraged to review the information and provide your input and comments to the MedImpact P & T and Formulary Committees. The MedImpact P & T and Formulary Committees use the following criteria in the evaluation of drug selection for the MedPerform Formulary:

Drug safety profile Drug efficacy Comparison of relevant therapeutic benefits to current formulary agents of

similar use, and to minimize therapeutic duplication where possible Cost-effectiveness relative to comparable therapies

How to Use the Formulary The Formulary is a list of medications available to MedImpact members under their pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name (in capital letters) and by therapeutic drug category. In situations where an FDA approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand, unless specifically noted. Any drug not found in this Formulary listing, or any Formulary updates published by MedImpact shall be considered a Non-Formulary drug. All drugs are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name is bolded. For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols: AGE Age Edit Coverage may depend on patient age CU Concurrent Use Edit Coverage or lack thereof may depend upon

concurrent use of another drug MD Physician Specialty Edit Coverage may depend on prescribing

physician’s specialty or board certification

PA Prior Authorization Requires specific physician request process QL Quantity Limit Coverage may be limited to specific quantities

per prescription and/or time period ST Step Therapy Coverage may depend on previous use of

another drug

Please refer to the prescribing guideline appendix within this document for details regarding specific agents. Benefit Coverage and Limitations This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in the Formulary. The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or MedImpact at (800) 788-2949. Excluded Agents As new drugs become available, they will be considered for coverage under the MedPerform Formulary. The plan administrator has the right to decide what drugs are covered and to what extent, as well as the right to modify coverage including the exclusion of any prescription drugs. Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives.

EXCLUDED DRUGS

FORMULARY THERAPEUTIC

ALTERNATIVES THERAPEUTIC DRUG CLASS

VELTIN clindamycin/tretinoin,

ZIANA ACNE AGENTS, TOPICAL

KADIAN

morphine sulfate ER tablets, oxycodone ER, NUCYNTA, NUCYNTA

ER

ANALGESICS, NARCOTICS

BELBUCA BUTRANS PATCH ANALGESICS, NARCOTICS

ABSTRAL, FENTORA, LAZANDA, ONSOLIS, SUBSYS

fentanyl citrate lozenge ANALGESICS, NARCOTICS

GRALISE immediate-release

gabapentin ANTICONVULSANTS

ACTIVE-PAC KIT,

SMARTRX GABA-V KIT, SMART RX GABA KIT

immediate-release

gabapentin & lidocaine/menthol topical,

or capsaicin/methyl salicylate/menthol topical

ANTICONVULSANTS

HORIZANT immediate-release

gabapentin, ropinirole, pramipexole

ANTICONVULSANTS (RESTLESS LEG

SYNDROME/POST HERPETIC NEURALGIA)

FORFIVO XL bupropion ER ANTIDEPRESSANTS

IRENKA duloxetine ANTIDEPRESSANTS

KHEDEZLA desvenlafaxine succinate ER, desvenlafaxine ER

(Ranbaxy) ANTIDEPRESSANTS

PEXEVA paroxetine ANTIDEPRESSANTS

ZUPLENZ ondansetron ODT ANTIEMETIC AGENTS

NYATA nystatin topical ANTI-INFECTIVE

DAXBIA cephalexin ANTI-INFECTIVE

ZIPSOR, ZORVOLEX

diclofenac ANTI-INFLAMMATORY

NON-STEROIDAL

NAPRELAN naproxen ANTI-INFLAMMATORY

NON-STEROIDAL

VIVLODEX meloxicam ANTI-INFLAMMATORY

NON-STEROIDAL

TIVORBEX indomethacin ANTI-INFLAMMATORY

NON-STEROIDAL

VIMOVO

naproxen & esomeprazole magnesium, lansoprazole,

omeprazole, or pantoprazole

ANTI-INFLAMMATORY NON-STEROIDAL

COMBINATION AGENTS

DUEXIS famotidine & ibuprofen ANTI-INFLAMMATORY

NON-STEROIDAL COMBINATION AGENTS

CAPXIB celecoxib &

capsaicin/menthol topical patch

ANTI-INFLAMMATORY NON-STEROIDAL

CYCLOOXYGENASE-2 (COX-2) SELECTIVE

INHIBITOR

RAYOS immediate-release

prednisone ANTI-INFLAMMATORY

STEROIDAL

MedPerform LOW Formulary

37010 MedPerform Low Formulary – July 2017 ii

EXCLUDED DRUGS


ALTERNATIVES

THERAPEUTIC DRUG CLASS

ZONACORT, LOCORT

dexamethasone 1.5mg tab

ANTI-INFLAMMATORY STEROIDAL

MOTOFEN diphenoxylate/atropi

ne ANTI-MOTILITY

HYCOFENIX codeine/pseudoephedrine/guaifenesin sol

ANTITUSSIVES

APTENSIO XR, ADZENYS XR

ODT

dextroamphetamine/ amphetamine,

methylphenidate

ATTENTION DEFICIT-HYPERACTIVITY

(ADHD)/NARCOLEPSY

CIMZIA, KEVZARA,

SIMPONI 50mg, TALTZ

HUMIRA, ENBREL, COSENTYX, STELARA,

XELJANZ/XR, OTEZLA, *SIMPONI

100mg (*for diagnosis of

ulcerative colitis only)

AUTOIMMUNE DISEASE

BINOSTO alendronate 70mg,

ibandronate BONE RESORPTION

INHIBITORS

DURLAZA aspirin (OTC),

clopidogrel CARDIOLOGY

YOSPRALA aspirin (OTC) CARDIOLOGY

GONITRO nitroglycerin CARDIOLOGY

BEAU RX KELOCOTE,

RECEDO DERMATOLOGY

DERMAPAK PLUS

tretinoin topical DERMATOLOGY

ACCUCAINE lidocaine topical DERMATOLOGY

PEDIPAK ciclopirox DERMATOLOGY

SYNERDERM

OTC EMOLLIENTS (EUCERIN, CETAPHIL, VASELINE,

AQUAPHOR)

DERMATOLOGY

URE-K, KERALAC, UTOPIC, UREVAZ,

DERMASORB XM

urea 40%, urea 50% DERMATOLOGY

PENNSAID diclofenac sodium

1% topical DERMATOLOGY -

ANTIINFLAMMATORY ADLYXIN,

BYDUREON, BYETTA,

TANZEUM

TRULICITY, VICTOZA

DIABETES

XULTOPHY, SOLIQUA

TRULICITY, VICTOZA, LANTUS,

TOUJEO DIABETES

FARXIGA, XIGDUO XR

INVOKANA, INVOKAMET,INVOK

AMET XR, JARDIANCE, SYNJARDY,

SYNJARDY XR

DIABETES

GLUMETZA metformin ER DIABETES

NESINA, KAZANO, OSENI,

ONGLYZA, KOMBIGLYZE

XR

JENTADUETO, JENTADUETO XR,

TRADJENTA, JANUVIA, JANUMET,

JANUMET XR

DIABETES

ALL OTHER MANUFACTUR

ERS OF DIABETIC TEST

STRIPS AND METERS

ABBOTT (PRECISION AND

FREESTYLE BRAND)

DIABETIC SUPPLIES (TEST STRIPS, METERS)

EXCLUDED DRUGS


ALTERNATIVES


LEVITRA, STENDRA, STAXYN

VIAGRA DRUGS TO TREAT

IMPOTENCY

AUVI-Q epinephrine 0.3mg

or 0.15mg auto-injector

EMERGENCY TREATMENT OF

ALLERGIC REACTIONS (TYPE 1)

GENOTROPIN, HUMATROPE,

NUTROPIN, NUTROPIN AQ, NUTROPIN AQ

NUSPIN, SAIZEN,

ZOMACTON

OMNITROPE, NORDITROPIN

GROWTH HORMONES

VIEKIRA PAK, DAKLINZA

HARVONI, EPCLUSA

HEPATITIS C

ESTROGEL DIVIGEL HORMONAL DEFICIENCY

NATESTO, TESTIM,

VOGELXO, FORTESTA

ANDROGEL, AXIRON

HORMONAL DEFICIENCY

PRESTALIA amlodipine and benazepril hcl

HYPERTENSION

APIDRA, APIDRA

SOLOSTAR, NOVOLOG, NOVOLOG FLEXPLEN

HUMALOG INSULINS

LEVEMIR, BASAGLAR,

TRESIBA LANTUS, TOUJEO INSULINS

NOVOLIN HUMULIN INSULINS

ALTOPREV, LESCOL XL

atorvastatin, lovastatin,

pravastatin, simvastatin, rosuvastatin

LIPID IRREGULARITY

ANTARA fenofibrate/ micronized/

nanocrystallized LIPOTROPICS

DELZICOL, DIPENTUM

balsalazide disodium, APRISO, LIALDA, PENTASA,

sulfasalazine

LOWER GASTROINTESTINAL

DISORDERS

ONZETRA, ZEMBRACE SYMTOUCH, TREXIMET

sumatriptan MIGRAINE

EXTAVIA

REBIF, GILENYA, PLEGRIDY,

TECFIDERA, AVONEX,

GLATOPA, AUBAGIO

MULTIPLE SCLEROSIS

METHAVER Individual vitamin

components MULTIVITAMIN

PREPARATIONS

OMNARIS, ZETONNA,

BECONASE AQ, TICANASE

Nasal triamcinolone, flunisolide, fluticasone, budesonide,

mometasone, QNASL

NASAL ANTI-INFLAMMATORY

TICALAST Azelastine &

fluticasone nasal sprays

NASAL ANTI-INFLAMMATORY/ANTI-

HISTAMINE COMBINATION

QSYMIA phentermine &

topiramate OBESITY AGENTS


37010 MedPerform Low Formulary – July 2017 iii

EXCLUDED DRUGS


ALTERNATIVES


ZIOPTAN

latanoprost, travoprost, LUMIGAN,

TRAVATAN Z

OPHTHALMIC GLAUCOMA

EVZIO

NARCAN NASAL SPRAY

OPIOID REVERSAL

LASTACAFT, BEPREVE, EMADINE,

PAZEO

PATADAY, olopatadine

OPHTHALMIC ANTIHISTAMINES

ARESTIN N/A ORAL/PHARYNGEAL

DISORDERS

PANCREAZE, PERTZYE

lipase/protease/amylase, CREON,

ZENPEP PANCREATIC ENZYMES

AIRDUO RESPICLICK

AND AUTHORIZED

GENERIC FLUTICASONE/SALMETEROL

(55/14mcg, 113/14mcg, and

232/14mcg)

ADVAIR, BREO ELIPTA,

SYMBICORT, DULERA

RESPIRATORY ASTHMA

UTIBRON, BEVESPI

STIOLTO RESPIRATORY COPD

ALVESCO, FLOVENT DISKUS,

FLOVENT HFA

ASMANEX HFA, ASMANEX

TWISTHALER, PULMICORT

FLEXHALER, QVAR

RESPIRATORY ASTHMA

PROVENTIL HFA,

levalbuterol HFA

PROAIR HFA, VENTOLIN HFA

RESPIRATORY ASTHMA AND COPD

TUDORZA PRESSAIR,

SEEBRI NEOHALER

SPIRIVA HANDIHALER,

SPIRIVIA RESPIMAT

RESPIRATORY COPD

NORITATE metronidazole

0.75% cream, gel or lotion

ROSACEA AGENTS, TOPICAL

EDLUAR, INTERMEZZO,

ROZEREM, ZOLPIMIST

eszopiclone, zaleplon, zolpidem

SEDATIVE-HYPNOTICS, NON-BARBITURATE

AMRIX, FEXMID,

FLEXEPAX

cyclobenzaprine 5mg or 10mg

SKELETAL MUSCLE RELAXANTS

ALLZITAL butalbital/acetamino

phen TENSION HEADACHE

TIROSINT levothyroxine THYROID HORMONES Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives.


37010 MedPerform Low Formulary – July 2017 iii

Depending upon a member’s specific benefit parameters, the following topics may apply: 1. Generic Substitution

When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name indicated. The generic names are bolded in the formulary listing wherever an FDA approved generic drug product is available. Greater economy is realized through the use of generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become available generically are subject to review by MedImpact’s Pharmacy and Therapeutics Committee. MedImpact approves such multi-source drugs for addition to the MAC list based on the following criteria:

A multi-source drug product manufactured by at least one (1) nationally marketed company.

At least one (1) of the generic manufacturer’s products must have an “A” rating or the generic product has been determined to be unassociated with efficacy, safety or bioequivalency concerns by the MedImpact P & T Committee.

Drug product will be approved for generic substitution by the MedImpact P & T Committee.

This list is reviewed and updated periodically based on the clinical literature and pharmacokinetic characteristics of currently available versions of these drug products. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic. If a physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the medication request process.

2. Three Tier Benefit The Formulary may be applied to a three tier benefit design, where the member shares the cost of prescription drug therapy at three levels of copayment. In most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under the second copay tier, and branded drugs not on the Formulary will be covered under the third or highest copay tier.

3. Medication Request Process Depending upon plan benefit design, a medication request process may apply as follows:

A. Formulary Agents Drugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per MedImpact P & T Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.

B. Non-Formulary Agents Any drug not found in the Formulary listing, or any Formulary updates published by MedImpact, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When a member gives a prescription order for a non-formulary drug to a pharmacist, the pharmacist will evaluate the patient’s drug history and contact the physician to determine if there is a reasonable medical need for a non-formulary drug. Each request will be reviewed on an individual patient need basis. Approval will be given if a documented medical need exists. The following basic guidelines are used:

The use of Formulary Drugs is contraindicated in the patient. The patient has failed an appropriate trial of Formulary or related

agents. The choices available in the Formulary are not suited for the

present patient care need, and the drug selected is required for patient safety.

The use of a Formulary drug may provoke an underlying condition, which would be detrimental to patient care.

If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended.

C. Obtaining Coverage Coverage, questions or information regarding the medication request or formulary process may be obtained by:

1. Faxing a completed Medication Request Form to MedImpact at (858) 790-7100.

2. Contacting MedImpact at (800) 788-2949 and providing all necessary information requested.

MedImpact will provide an authorization number, specific for the medical need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior Authorization is

generally not available for drugs that are specifically excluded by benefit design.

4. General Exclusions A. Over the Counter (OTC) medications or their equivalents, unless

otherwise specified in the Formulary listing. B. Nicotine Smoking Cessation products (i.e., transdermal nicotine,

nicotine gum, nicotine inhaler). C. Drugs specifically listed as not covered. D. Any drug products used for cosmetic purposes. E. Experimental drug products or any drug product used in an

experimental manner. F. Replacement of lost or stolen medication. G. Non self-administered injectable drug products unless otherwise

specified in the Formulary listing. H. Foreign sourced drugs or drugs not approved by the United States

Food & Drug Administration.

The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies.

5. Pharmacist and Physician Communication The Formulary is a tool to promote cost-effective prescription drug use. The P & T and Formulary Committees have made every attempt to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task. MedImpact welcomes the participation of physicians, pharmacists, and ancillary medical providers, in this dynamic process. Physicians and pharmacists are highly encouraged to direct any suggestions, comments or formulary additions to MedImpact at the following address:

Chairperson, Pharmacy & Therapeutics Committee MedImpact Healthcare Systems, Inc. 10181 Scripps Gateway Court San Diego, CA 92131


37010 MedPerform Low Formulary – July 2017 iv

Foreword ................................................................................................................ i ALLERGY .............................................................................................................. 1

Allergenic extracts ........................................................................................... 1 2nd Generation Antihistamine & Decongestant Combinations ......................... 1 Antihistamines - 1st Generation ....................................................................... 1 Antihistamines - 2nd Generation ...................................................................... 1 Nasal Anti-Inflammatory Steroids ..................................................................... 1 Nasal Antihistamines ....................................................................................... 1

ANTIEMESIS/ANTIVERTIGO ................................................................................ 1 Antiemetic/Antivertigo Agents .......................................................................... 1

ASTHMA ................................................................................................................ 1 Beta-Adrenergic Agents ................................................................................... 1 Beta-Adrenergic & Anticholinergic Combinations ............................................. 1 Beta-Adrenergic & Glucocorticoid Combinations ............................................. 1 General Bronchodilator Agents ........................................................................ 1 Leukotriene Receptor Antagonists ................................................................... 1 Mast Cell Stabilizers ........................................................................................ 1 Oral Inhaled Corticosteroids ............................................................................ 1 Phosphodiesterase-4 (PDE4) Inhibitors ........................................................... 1 Xanthines ......................................................................................................... 1

AUTONOMIC NERVOUS SYSTEM DISORDERS ................................................. 1 Alzheimer's Therapy, Nmda Receptor Antagonists .......................................... 1 Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors ......... 1 Cholinesterase Inhibitors ................................................................................. 1

BEHAVIORAL HEALTH - ANTIDEPRESSANTS ................................................... 1 Alpha-2 Receptor Antagonist Antidepressants ................................................. 1 MAOIs - Non-Selective & Irreversible............................................................... 1 Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) .............................. 1 Selective Serotonin Reuptake Inhibitors (SSRIs) ............................................. 1 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)........................................ 1 SSRI & Antipsych, Atyp, Dopamine & Serotonin Antag Comb ......................... 1 SSRI & 5HT1A Partial Agonist Antidepressants ............................................... 1 SSRI, Serotonin Receptor Modulator Antidepressants ..................................... 1 Serotonin-Norepinephrine Reuptake-Inhibitors (SNRIs) ................................... 1 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib ......................................... 1

BEHAVIORAL HEALTH - OTHER ......................................................................... 2 Adrenergics, Aromatic, Non-Catecholamine .................................................... 2 Anti-Alcoholic Preparations .............................................................................. 2 Anti-Anxiety Drugs ........................................................................................... 2 Anti-Mania Drugs ............................................................................................. 2 Anti-Psychotics, Phenothiazines ...................................................................... 2 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed ................................... 2 Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed ............................. 2 Antipsychotics, Dopamine & Serotonin Antagonists ......................................... 2 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists ......................... 2 Antipsychotics, Dopamine Antagonists, Thioxanthenes ................................... 2 Antipsychotics, Dopamine Antagonists, Butyrophenones ................................ 2 Barbiturates ..................................................................................................... 2 Narcolepsy and Sleep Disorder Therapy Agents ............................................. 2 Narcotic Antagonists ........................................................................................ 2 Sedative-Hypnotics, Non-Barbiturate ............................................................... 2 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy .................... 2 Treatment for Attention Deficit-Hyperactivity (ADHD), NRI-Type ..................... 2

CARDIOVASCULAR DISEASE - ARRHYTHMIA ................................................... 2 Antiarrhythmics ................................................................................................ 2

CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ................................... 2 Digitalis Glycosides .......................................................................................... 2

CARDIOVASCULAR DISEASE - HYPERTENSION .............................................. 2 ACE Inhibitor/Calcium Channel Blocker Combinations .................................... 2 ACE Inhibitor/Thiazide & Thiazide-Like Diuretic ............................................... 2 Alpha-Adrenergic Blocking Agents ................................................................... 2 Alpha/Beta-Adrenergic Blocking Agents .......................................................... 3 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Combinations ................................................................................................... 3 Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ................... 3 Angiotensin II Receptor Blocker-Beta Blocker Comb. ...................................... 3 Angiotensin Receptor Antagonists & Calcium Channel Blockers ..................... 3 Antihypertensives, ACE Inhibitors .................................................................... 3 Antihypertensives, Angiotensin Receptor Antagonists ..................................... 3 Antihypertensives, Sympatholytic .................................................................... 3 Antihypertensives, Vasodilators ....................................................................... 3 Beta-Adrenergic Blocking Agents .................................................................... 3 Beta-Adrenergic Blocking Agents/Thiazide & Related ...................................... 3 Calcium Channel Blocking Agents ................................................................... 3 Loop Diuretics .................................................................................................. 3 Potassium Sparing Diuretics ............................................................................ 3 Potassium Sparing Diuretics in Combination ................................................... 3 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ............... 3 Pulmonary Anti-HTN, Endothelin Receptor Antagonists .................................. 3 Pulmonary Anti-HTN, Prostacyclin-Type .......................................................... 3 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulator ........................... 3 Thiazide & Related Diuretics ............................................................................ 3

CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ...................................... 3 Antihyperlipidemic - APO B-100 Synthesis Inhibitor ............................................... 3

Antihyperlipidemic - HMG CoA Reductase Inhibitors ....................................... 3 Antihyperlipidemic - MTP Inhibitors .................................................................. 3

Antihyperlipidemic – PCSK9 Inhibitors ............................................................ 3 Bile Salt Sequestrants ..................................................................................... 3 Lipotropics ....................................................................................................... 3 Niacin Preparations ......................................................................................... 4

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ............................ 4 Adrenergic Vasopressor Agents ...................................................................... 4 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ................................ 4 Antihyperlipidemic - HMG-CoA & Calcium Channel Blocker Combinations ..... 4

Heart Rate Reducing, Selective I(F) Current Inhib. ............................................... 4 CARDIOVASCULAR DISEASE - VASODILATION ............................................... 4 Vasodilators, Combination .................................................................................... 4

Vasodilators, Coronary .................................................................................... 4 CONTRACEPTION/OXYTOCICS ......................................................................... 4

Contraceptives, Intravaginal, Systemic ........................................................... 4 Contraceptives, Oral ....................................................................................... 4 Contraceptives, Transdermal .......................................................................... 4 Oxytocics ........................................................................................................ 4

COUGH AND COLD ............................................................................................. 4 1st Generation Antihistamine & Decongestant Combinations.......................... 4 Narcotic Antitussive-1st Generation Antihistamine-Decongestants ................. 4 Narcotic Antitussive-1st Generation Antihistamines ........................................ 4 Narcotic Antitussive-Anticholinergic Comb. ..................................................... 4 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations. ........... 4

DERMATOLOGY - ACNE ..................................................................................... 4 Acne Agents, Systemic ................................................................................... 4 Acne Agents, Topical ...................................................................................... 4 Keratolytic-Glucocorticoid Combinations ......................................................... 4 Keratolytics ..................................................................................................... 4 Rosacea Agents, Topical ................................................................................ 4 Vitamin A Derivatives ...................................................................................... 4

DERMATOLOGY - ANTIINFECTIVE ..................................................................... 4 Topical Antibiotics ........................................................................................... 4 Topical Antifungals .......................................................................................... 4 Topical Antiparasitics ...................................................................................... 5 Topical Antivirals ............................................................................................. 5 Topical Sulfonamides ...................................................................................... 5

DERMATOLOGY - ANTIINFLAMMATORY ........................................................... 5 Topical Anti-Inflammatory Steroidal ................................................................. 5 Topical Anti-Inflammatory, NSAIDs ................................................................. 5 Topical Antibiotics/Antiinflammatory, Steroidal ................................................ 5

DERMATOLOGY - MISCELLANEOUS ................................................................. 5 Antiperspirants ................................................................................................ 5 Antiseborrheic Agents ..................................................................................... 5 Topical Antineoplastic & Premalignant Lesion Agents ..................................... 5 Topical Local Anesthetics ................................................................................ 5

DERMATOLOGY - PIGMENTATION DISORDERS .............................................. 5 Topical Hyperpigmentation Agents .................................................................. 5

DERMATOLOGY - PSORIASIS/ECZEMA ............................................................ 5 Antipsoriatic Agents, Systemic ........................................................................ 5 Antipsoriatics Agents ....................................................................................... 5 Topical Immunosuppressive Agents ................................................................ 5 Topical Phosphodiesterase (PDE-4) Inhibitor .................................................. 5

DIABETES ............................................................................................................ 5 Antihyperglycemics, Incretin Mimetics (GLP-1 Receptor Agonists) ................. 5 Antihyperglycemics, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) ............ 5 Antihyperglycemics, Amylin Analog-Type ........................................................ 5 Antihyperglycemics, DPP-4 Inhibitors ............................................................. 5 Antihyperglycemics, (DPP-4) Inhibitor & Biguanide Combinations .................. 5 Antihyperglycemics, Insulin-Release Stimulant Type ...................................... 5 Antihyperglycemic, Insulin-Response Enhancers (Non-Sulfonylurea) ............. 5 Antihyperglycemics, Biguanide Type (Non-Sulfonylurea) ................................ 6 Antihyperglycemics, Insulin-Rel Stim. & Biguanide Combinations ................... 6 Antihyperglycemic, Insulin-Response & Release Combinationsination ........... 6 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations ............. 6 Antihyperglycemic-Glucocorticoid Receptor Blocker ....................................... 6 Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ........................ 6 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination ................................................................................... 6 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination ........................... 6 Diabetic Supplies ............................................................................................ 6 Diabetic Ulcer Preparations, Topical ............................................................... 6 Hyperglycemics ............................................................................................... 6 Insulins ............................................................................................................ 6 Syringes & Accessories .................................................................................. 6

EAR - GENERAL DISORDERS ............................................................................ 6 Ear Preparations, Miscellaneous Anti-Infectives .............................................. 6 Ear Preparations, Antibiotics ........................................................................... 6 Otic Preparations, Anti-Inflammatory-Antibiotics ............................................. 6 Otic Preparations, Local Anesthetics ............................................................... 6

ELECTROLYTE REGULATION ............................................................................ 6 Electrolyte Depleters ....................................................................................... 6 Potassium Replacement ................................................................................. 6

ENDOCRINE DISORDER - FERTILITY ................................................................ 6 Drugs to Treat Impotency ................................................................................ 6 Fertility Stimulating Preparations, Non-FSH .................................................... 6 Follicle Stimulating/Luteinizing Hormones ....................................................... 6


37010 MedPerform Low Formulary – July 2017 v

Pregnancy Facilitating/Maintaining Agents, Hormonal ..................................... 6 ENDOCRINE DISORDER - OTHER ...................................................................... 6

Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants ...................... 6 Antidiuretic & Vasopressor Hormones ............................................................. 6 Bone Formation Stim. Agents - Parathyroid Hormone ..................................... 6 Bone Resorption Inhibitor & Vitamin D Combinations ...................................... 6 Bone Resorption Inhibitors ............................................................................... 6 Growth Hormone Receptor Antagonists ........................................................... 6 Growth Hormones ............................................................................................ 6 Hyperparathyroid Tx Agents, Vitamin D Analog-Type ...................................... 6 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ................................ 6 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) .............................. 6 Pituitary Suppressive Agents ........................................................................... 7

ENDOCRINE DISORDER - THYROID .................................................................. 7 Antithyroid Preparations ................................................................................... 7 Iodine Containing Agents ................................................................................. 7 Thyroid Hormones ........................................................................................... 7

EYE - GENERAL DISORDERS ............................................................................. 7 Eye Antibiotic-Corticoid Combinations ............................................................. 7 Eye Antihistamines .......................................................................................... 7 Eye Antiinflammatory Agents ........................................................................... 7 Eye Antivirals ................................................................................................... 7 Eye Sulfonamides ............................................................................................ 7

EYE - MISCELLANEOUS ...................................................................................... 7 Ophthalmic Cystine Delpleting Agents ............................................................. 7 Ophthalmic Anti-Inflammatory Immunomodulator-Type ................................... 7 Ophthalmic Antibiotics ..................................................................................... 7 Ophthalmic Mast Cell Stabilizers ..................................................................... 7

EYE - GLAUCOMA ................................................................................................ 7 Carbonic Anhydrase Inhibitors ......................................................................... 7 Miotics/Other Intraocular Pressure Reducers................................................... 7 Mydriatics ........................................................................................................ 7 Hyperuricemia Treatments - Purine Inhibitors .................................................. 7 Uricosuric Agents ............................................................................................. 7

HEMATOLOGICAL DISORDERS .......................................................................... 7 Anticoagulants, Coumarin Type ....................................................................... 7 Direct Factor XA Inhibitors ............................................................................... 7 Hematinics, Other ............................................................................................ 7 Hemorrheologic Agents ................................................................................... 7 Heparin & Related Preparations ...................................................................... 7 Leukocyte (WBC) Stimulants ........................................................................... 8 Platelet Aggregation Inhibitors ......................................................................... 8 Platelet Reducing Agents ................................................................................. 8 Thrombopoietin Receptor Agonists .................................................................. 8 Vitamin K Preparations .................................................................................... 8

HORMONAL DEFICIENCY.................................................................................... 8 Androgenic Agents .......................................................................................... 8 Estrogen/Androgen Combinations ................................................................... 8 Estrogenic Agents ............................................................................................ 8 Progestational Agents ...................................................................................... 8

IMMUNOSUPPRESSION/MODULATION.............................................................. 8 Immunomodulators .......................................................................................... 8 Immunosuppressives ....................................................................................... 8

INFECTIOUS DISEASE - BACTERIAL .................................................................. 8 Absorbable Sulfonamides ................................................................................ 8 Betalactams ..................................................................................................... 8 Cephalosporins - 1st Generation ..................................................................... 8 Cephalosporins - 2nd Generation .................................................................... 8 Cephalosporins - 3rd Generation ..................................................................... 8 Chemotherapeutics, Antibacterial, Miscellaneous. ........................................... 8 Ketolides .......................................................................................................... 8 Lincosamides ................................................................................................... 8 Macrolides ....................................................................................................... 8 Nitrofuran Derivatives ...................................................................................... 8 Oxazolidinones ................................................................................................ 8 Penicillins ......................................................................................................... 8 Quinolones ...................................................................................................... 8 Tetracyclines ................................................................................................... 9

INFECTIOUS DISEASE - FUNGAL ....................................................................... 9 Antifungal Agents ............................................................................................. 9 Antifungal Antibiotics ....................................................................................... 9

INFECTIOUS DISEASE - MISCELLANEOUS ....................................................... 9 Aminoglycosides .............................................................................................. 9 Anti-Mycobacterium Agents ............................................................................. 9 Antileprotics ..................................................................................................... 9 Antitubercular Antibiotics ................................................................................. 9 Rifamycins and Related Derivative Antibiotics ................................................. 9 Vancomycin & Derivatives ............................................................................... 9

INFECTIOUS DISEASE - PARASITIC ................................................................... 9 Amebacides ..................................................................................................... 9 Anaerobic Antiprotozoal-Antibacterial Agents .................................................. 9 Anthelmintics ................................................................................................... 9 Antimalarial Drugs ........................................................................................... 9 Antiprotozoal Drugs, Miscellaneous ................................................................. 9

INFECTIOUS DISEASE - VIRAL ........................................................................... 9 Antiretroviral Combination, Integrase Inhibitors ................................................ 9 Antivirals, General ........................................................................................... 9

Antivirals, HIV-Spec, Non-Peptidic Protease Inhibitors .................................... 9 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analogs ..................................... 9 Antivirals, HIV-Spec, Nucleoside Analog, RTI Combinations........................... 9 Antivirals, HIV-Specific, CCR5 Co-Receptor Antagonists ................................ 9 Antivirals, HIV-Specific, Fusion Inhibitors ........................................................ 9 Antivirals, HIV-Specific, Non-Nucleoside, RTI ................................................. 9 Antivirals, HIV-Specific, Nucleoside Analog, RTI ............................................. 9 Antivirals, HIV-Specific, Nucleotide Analog, RTI .............................................. 9 Antivirals, HIV-Specific, Protease Inhibitor Combinations ................................ 9 Antivirals, HIV-Specific, Protease Inhibitors .................................................... 9 Antivirals, HIV-1 Integrase Strand Transfer Inhibitors ...................................... 9 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ............. 9 Cytochrome P450 Inhibitors .......................................................................... 10 Hepatitis B Treatment Agents ....................................................................... 10 Hepatitis C Combination Agents.................................................................... 10 Hepatitis C Treatment Agents ....................................................................... 10

INFLAMMATORY DISEASE ............................................................................... 10 Anti-Arthritic & Chelating Agents ................................................................... 10 Anti-Arthritic, Folate Antagonist Agents ......................................................... 10 Anti-Inflammatory Tumor Necrosis Factor Inhibitors ...................................... 10 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ........................................ 10 Bradykinin B2 Receptor Antagonists ............................................................. 10 Glucocorticoids ............................................................................................. 10 Mineralocorticoids ......................................................................................... 10 Monoclonal antibody-human interleukin ........................................................ 10 NSAIDs, Cyclooxygenase Inhibitor-Type ....................................................... 10

LOCAL ANESTHESIA ......................................................................................... 10 Local Anesthetics .......................................................................................... 10

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY ....... 10 Bowel Antiinflamatory Agents ........................................................................ 10 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ........................................ 10 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ..................................... 10 Hemorrhoidal Preparations ........................................................................... 10 Rectal Preparations ....................................................................................... 10 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) .................................... 10

LOWER GASTROINTESTINAL DISORDERS - OTHER ..................................... 10 Ammonia Inhibitors ....................................................................................... 10 Antidiarrheals ................................................................................................ 10 Bile Salts ....................................................................................................... 10 Laxatives & Cathartics .................................................................................. 10 Narcotic Antagonists, Peripherally-Acting ...................................................... 10 Tryptophan Hydroxylase Inhibitor .................................................................. 10 Glucagon-Like Peptide (GLP-2) Analogs ....................................................... 10

MISCELLANEOUS AGENTS .............................................................................. 10 Anaphylaxis Therapy Agents ......................................................................... 10 Parasympathetic Agents ............................................................................... 11 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase.................................. 11

NEOPLASTIC DISEASE ..................................................................................... 11 Alkylating Agents........................................................................................... 11 Antiandrogenic Agents .................................................................................. 11 Antimetabolites ............................................................................................. 11 Antineoplastic - Aromatase Inhibitors ............................................................ 11 Antineoplastic – B Cell Lymphoma 2(BCL-2) Inhibitors ................................. 11 Antineoplastic – Hedgehog Pathway Inhibitors.............................................. 11 Antineoplastic – Janus Kinase (JAK) Inhibitors ............................................. 11 Antineoplastic – MEK1 and MEK2 Kinase Inhibitors ..................................... 11 Antineoplastic - Topoisomerase I Inhibitors ................................................... 11 Antineoplastic - Immunomodulator Agents .................................................... 11 Antineoplastic - Systemic Enzyme Inhibitors ................................................. 11 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ................................... 11 Antineoplastics, Miscellaneous ..................................................................... 11 Antineoplastic mTOR Kinase Inhibitors ......................................................... 11 Chemotherapy Rescue/Antidote Agents ........................................................ 11 Selective Estrogen Receptor Modulators (SERM) ......................................... 11 Selective Retinoid X Receptor Agonists (RXR) ............................................. 11 Steroid Antineoplastics .................................................................................. 11

NEUROLOGICAL DISEASE - MISCELLANEOUS .............................................. 11 Agents to Treat Multiple Sclerosis ................................................................. 11 Fibromyalgia Agents, Serotonin-Norepinephrine Reuptake Inhibitors ............ 11 Movement Disorders (Drug Therapy) ............................................................ 11

ORAL/PHARYNGEAL DISORDERS ................................................................... 11 Dental Aids & Preparations ........................................................................... 12 Nose Preparations, Antibiotics ...................................................................... 12 Nose Preparations, Miscellaneous (Rx) ........................................................ 12

OTHER DRUGS .................................................................................................. 12 Appetite Stim. For Anorexia, Cachexia, Wasting Synd. ................................. 12 General Inhalation Agents ............................................................................. 12 Metabolic disease enzyme replace, hypophosphatasia ................................. 12 Needles/Needleless Devices ......................................................................... 12 Nucleic Acid/Nucleotide Supplements ........................................................... 12 Somatostatic Agents ..................................................................................... 12 Drugs to treat hereditary tyrosinemia ............................................................ 12

OTHER RESPIRATORY DISORDERS ............................................................... 12 Antifibrotic Therapy – Pyridone Analogs ........................................................ 12 Cystic Fibrosis-Cftr Potentiator & Corrector Comb. ....................................... 12 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiator12 Mucolytics ..................................................................................................... 12


37010 MedPerform Low Formulary – July 2017 vi

Pulmonary Fibrosis – Systemic Enzyme Inhibitors ......................................... 12 PAIN MANAGEMENT - ANALGESICS ................................................................ 12

Analgesic, Non-Salicylate & Barbiturate Combinations. ................................. 12 Analgesic, Salicylate, Barbiturate & Xanthine Comb ...................................... 12 Analgesic, Non-Salicylate, Barbiturate & Xanthine Comb .............................. 12 Analgesic/Antipyretics, Salicylates ................................................................. 12 Analgesics, Narcotics .................................................................................... 12 Antimigraine Preparations .............................................................................. 12 Narcoctic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations 12 Narcotic & Salicylate Analgesics, Barbiturate & Xanthine .............................. 12 Narcotic Analgesic & Non-Salicylate Analgesic Combinations ....................... 12 Narcotic Withdrawal Therapy Agents ............................................................. 12

PARKINSON’S DISEASE .................................................................................... 12 Antiparkinsonism Drugs, Anticholinergic ........................................................ 12 Antiparkinsonism Drugs, Other ...................................................................... 12 Decarboxylase Inhibitors ................................................................................ 13

SEIZURE DISORDER ......................................................................................... 13 Anticonvulsants.............................................................................................. 13

SKELETAL MUSCLE DISORDER ....................................................................... 13 Agents To Treat Periodic Paralysis ................................................................ 13 Skeletal Muscle Relaxants ............................................................................. 13

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ................................ 13 Pancreatic Enzymes ...................................................................................... 13

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ................... 13 Anticholinergics/Antispasmodics .................................................................... 13 Belladonna Alkaloids ..................................................................................... 13

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ...................... 13 Anti-Ulcer Preparations .................................................................................. 13 Anti-Ulcer-H.pylori Agents .............................................................................. 13 Anticholinergics, Quaternary Ammonium ....................................................... 13 Histamine H2-Receptor Inhibitors .................................................................. 13 Intestinal Motility Stimulants ........................................................................... 13 Proton-Pump Inhibitors .................................................................................. 13

URINARY TRACT - FUNCTIONAL DISORDERS ................................................ 13 Benign Prostatic Hypertrophy/Micturition Agents ........................................... 13 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents ...................................................................................................................... 13 Kidney Stone Agents ..................................................................................... 13 Overactive Bladder Agents, Beta-3 Adrenergic Recep ................................... 13 Urinary Tract Analgesic Agents ...................................................................... 13 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) ................................... 13 Urinary Tract Antispasmodic, M(3) Selective Antagonists. ............................. 13 Urinary Tract Antispasmodic/Antiincontinence Agent ..................................... 13

VAGINAL DISORDERS ....................................................................................... 13 Vaginal Antibiotics ......................................................................................... 13 Vaginal Antifungals ........................................................................................ 13 Vaginal Estrogen Preparations ...................................................................... 13 Vaginal Sulfonamides .................................................................................... 13

VITAMIN AND/OR MINERAL DEFICIENCY ........................................................ 13 Fluoride Preparations .................................................................................... 13 Folic Acid Preparations .................................................................................. 13 Multivitamin Preparations ............................................................................... 13 Pediatric Vitamin Preparations ....................................................................... 14 Prenatal Vitamin Preparations ....................................................................... 14 Vitamin B Preparations .................................................................................. 14 Vitamin D Preparations .................................................................................. 14

SPECIALTY INJECTABLE CROSS REFERENCE LISTING ............................... 15


37010 MedPerform Low Formulary – July 2017 1

ALLERGY Allergenic extracts PA 5-grass pollen extract ORALAIR PA short ragweed pollen extract RAGWITEK PA timothy grass pollen extract GRASTEK 2nd Generation Antihistamine & Decongestant Combinations p-ephed hcl/cetirizine hcl (OTC) ZYRTEC-D (OTC) p-ephed sul/loratadine CLARITIN-D 12 HOUR

CLARITIN-D 24 HOUR Antihistamines - 1st Generation hydroxyzine hcl ATARAX hydroxyzine pamoate VISTARIL promethazine hcl PHENERGAN Antihistamines - 2nd Generation cetirizine hcl (OTC) ZYRTEC (OTC) levocetirizine dihydrochloride XYZAL TABS loratadine (OTC) CLARITIN (OTC) Nasal Anti-Inflammatory Steroids QL flunisolide NASAREL QL fluticasone propionate FLONASE QL triamcinolone acetonide NASACORT AQ QL

QL beclomethasone dipropionate QNASL

QNASL CHILDREN QL mometasone furoate NASONEX Nasal Antihistamines QL azelastine hcl ASTELIN QL ASTEPRO ANTIEMESIS/ANTIVERTIGO Antiemetic/Antivertigo Agents QL dronabinol MARINOL meclizine hcl ANTIVERT ondansetron ZOFRAN ODT

QL ondansetron hcl ondansetron hcl solution

ZOFRAN ZOFRAN SOLUTION

prochlorperazine maleate COMPAZINE promethazine hcl PHENERGAN QL netupitant/palonosetron hcl AKYNZEO QL aprepitant EMEND prochlorperazine edisylate COMPAZINE SYRUP ASTHMA Beta-Adrenergic Agents albuterol sulfate ALBUTEROL SULFATE metaproterenol sulfate ALUPENT terbutaline sulfate BRETHINE albuterol sulfate PROAIR HFA

PROAIR RESPICLICK VENTOLIN HFA

QL formoterol fumarate PERFOROMIST QL olodaterol hcl STRIVERDI RESPIMAT QL salmeterol xinafoate SEREVENT DISKUS Beta-Adrenergic & Anticholinergic Combinations ipratropium/albuterol sulfate DUONEB ipratropium/albuterol sulfate COMBIVENT

COMBIVENT RESPIMAT QL tiotropium br/olodaterol hcl STIOLTO RESPIMAT Beta-Adrenergic & Glucocorticoid Combinations QL

QL fluticasone/salmeterol ADVAIR DISKUS

ADVAIR HFA QL fluticasone/vilanterol BREO ELLIPTA QL

QL mometasone/formoterol budesonide/formoterol fumarate

DULERA SYMBICORT

General Bronchodilator Agents ipratropium bromide ATROVENT QL ipratropium bromide ATROVENT HFA QL tiotropium bromide SPIRIVA QL tiotropium bromide SPIRIVA RESPIMAT Leukotriene Receptor Antagonists montelukast sodium SINGULAIR

Mast Cell Stabilizers cromolyn sodium INTAL Oral Inhaled Corticosteroids QL budesonide PULMICORT RESPULES QL beclomethasone dipropionate QVAR QL budesonide PULMICORT

FLEXHALER QL

QL mometasone furoate ASMANEX

ASMANEX HFA Phosphodiesterase-4 (PDE4) Inhibitors QL +

ST roflumilast DALIRESP

Xanthines aminophylline AMINOPHYLLIN theophylline anhydrous UNIPHYL theophylline anhydrous THEO-24 AUTONOMIC NERVOUS SYSTEM DISORDERS Alzheimer's Therapy, Nmda Receptor Antagonists QL memantine hcl NAMENDA QL memantine hcl NAMENDA XR Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors QL

QL

memantine hcl/donepezil hcl NAMZARIC NAMZARIC TITIRATION PACK

Cholinesterase Inhibitors donepezil hcl ARICEPT

ARICEPT ODT QL

QL galantamine hydrobromide RAZADYNE

RAZADYNE ER pyridostigmine bromide MESTINON QL rivastigmine EXELON PATCH rivastigmine tartrate EXELON neostigmine bromide PROSTIGMIN BEHAVIORAL HEALTH - ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants mirtazapine REMERON MAOIs - Non-Selective & Irreversible tranylcypromine sulfate PARNATE phenelzine sulfate NARDIL Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) bupropion hcl WELLBUTRIN

WELLBUTRIN SR WELLBUTRIN XL

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide CELEXA escitalopram oxalate LEXAPRO fluoxetine er PROZAC WEEKLY fluoxetine hcl PROZAC paroxetine hcl PAXIL sertraline hcl ZOLOFT Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) trazodone hcl DESYREL 300MG SSRI & Antipsych, Atyp, Dopamine & Serotonin Antag Comb QL olanzapine/fluoxetine SYMBYAX SSRI & 5HT1A Partial Agonist Antidepressants QL vilazodone hcl VIIBRYD SSRI, Serotonin Receptor Modulator Antidepressants QL vortioxetine hydrobromide TRINTELLIX Serotonin-Norepinephrine Reuptake-Inhibitors (SNRIs) QL desvenlafaxine ER (Ranbaxy

Brand) DESVENLAFAXINE ER (RANBAXY BRAND)

QL QL

desvenlafaxine succinate levomilnacipran hcl venlafaxine hcl

PRISTIQ FETZIMA EFFEXOR, EFFEXOR XR

Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib amitriptyline hcl ELAVIL



amoxapine ASENDIN clomipramine hcl ANAFRANIL desipramine hcl NORPRAMIN doxepin hcl SINEQUAN imipramine hcl TOFRANIL maprotiline hcl LUDIOMIL nortriptyline hcl PAMELOR BEHAVIORAL HEALTH - OTHER Adrenergics, Aromatic, Non-Catecholamine QL

QL amphet asp/amphet/d-amphet ADDERALL

ADDERALL XR QL

QL QL

dextroamphetamine sulfate DEXEDRINE DEXEDRINE SPANSULE ZENZEDI (5mg, 10mg)

QL dextroamphetamine tablet (2.5mg, 7.5mg, 15mg, 20mg, 30mg)

ZENZEDI

QL lisdexamfetamine dimesylate VYVANSE Anti-Alcoholic Preparations disulfiram ANTABUSE Anti-Anxiety Drugs alprazolam XANAX

ALPRAZOLAM INTENSOL

buspirone hcl BUSPAR VANSPAR

chlordiazepoxide hcl LIBRIUM clorazepate dipotassium TRANXENE T-TAB diazepam VALIUM lorazepam ATIVAN

LORAZEPAM INTENSOL meprobamate MILTOWN oxazepam SERAX Anti-Mania Drugs lithium carbonate ESKALITH

LITHOBID lithium citrate CIBALITH-S Anti-Psychotics, Phenothiazines chlorpromazine hcl THORAZINE fluphenazine hcl PROLIXIN perphenazine TRILAFON thioridazine hcl MELLARIL trifluoperazine hcl STELAZINE Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed QL QL

aripiprazole aripiprazole

ABILIFY SOLUTION ABILIFY TABLET

QL QL

aripiprazole ODT brexpiprazole

ABILIFY DISCMELT REXULTI

Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed QL cariprazine hcl VRAYLAR Antipsychotics, Dopamine & Serotonin Antagonists loxapine succinate LOXITANE Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists QL QL QL

asenapine maleate clozapine lurasidone hcl

SAPHRIS CLOZARIL LATUDA

QL olanzapine ZYPREXA QL olanzapine ODT ZYPREXA ZYDIS QL quetiapine fumarate SEROQUEL QL quetiapine fumarate ER SEROQUEL XR QL risperidone RISPERDAL QL risperidone ODT RISPERDAL M-TAB QL ziprasidone hcl GEODON Antipsychotics, Dopamine Antagonists, Thioxanthenes thiothixene NAVANE Antipsychotics, Dopamine Antagonists, Butyrophenones haloperidol HALDOL haloperidol lactate HALDOL ORAL CONC.

Barbiturates phenobarbital PHENOBARBITAL Narcolepsy and Sleep Disorder Therapy Agents QL modafinil PROVIGIL Narcotic Antagonists naltrexone hcl NARCAN naltrexone hcl REVIA Sedative-Hypnotics, Non-Barbiturate QL

chloral hydrate doxepin hcl

NOCTEC SILENOR

estazolam PROSOM QL eszopiclone LUNESTA QL

flurazepam hcl suvorexant

DALMANE BELSOMRA

temazepam RESTORIL triazolam HALCION QL zaleplon SONATA QL

zolpidem tartrate

AMBIEN AMBIEN CR

Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy QL QL

dexmethylphenidate hcl

FOCALIN FOCALIN XR

QL QL QL+ AGE QL+ AGE QL QL+ AGE QL

methylphenidate hcl methylphenidate hcl

CONCERTA METADATE CD METADATE ER METHYLIN CHEW TAB METHYLIN SOLN RITALIN RITALIN LA RITALT QUILLICHEW ER

QL methylphenidate ER suspension QUILLIVANT XR Treatment for Attention Deficit-Hyperactivity (ADHD), NRI-Type QL atomoxetine hcl STRATTERA CARDIOVASCULAR DISEASE - ARRHYTHMIA Antiarrhythmics amiodarone hcl CORDARONE disopyramide phosphate NORPACE flecainide acetate TAMBOCOR mexiletine hcl MEXITIL procainamide hcl PRONESTYL propafenone hcl RYTHMOL quinidine gluconate QUINAGLUTE quinidine sulfate QUINIDEX disopyramide phosphate NORPACE CR dofetilide TIKOSYN dronedarone hcl MULTAQ propafenone hcl RYTHMOL SR CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS Digitalis Glycosides digoxin LANOXIN DIGOXIN ORAL SOLN. CARDIOVASCULAR DISEASE - HYPERTENSION ACE Inhibitor/Calcium Channel Blocker Combinations amlodipine besylate/benazepril LOTREL ACE Inhibitor/Thiazide & Thiazide-Like Diuretic benazepril/hydrochlorothiazide LOTENSIN HCT captopril/hydrochlorothiazide CAPOZIDE enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide MONOPRIL HCT lisinopril/hydrochlorothiazide PRINZIDE

ZESTORETIC moexipril/hydrochlorothiazide UNIRETIC quinapril/hydrochlorothiazide ACCURETIC Alpha-Adrenergic Blocking Agents doxazosin mesylate CARDURA phenoxybenzamine hcl DIBENZYLINE prazosin hcl MINIPRESS



terazosin hcl HYTRIN Alpha/Beta-Adrenergic Blocking Agents carvedilol COREG labetalol hcl TRANDATE carvedilol phosphate COREG CR Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Combinations amlodipine/valsartan/hctz EXFORGE HCT olmesartan/amlodipin/hctz TRIBENZOR Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations azilsartan med/chlorthalidone

irbesartan/hydrochlorithiazide EDARBYCLOR AVALIDE

losartan/hydrochlorothiazide HYZAAR valsartan/hydrochlorothiazide DIOVAN HCT olmesartan/hydrochlorothiazide BENICAR HCT Angiotensin II Receptor Blocker-Beta Blocker Comb. nebivolol hcl/valsartan BYVALSON Angiotensin Receptor Antagonists & Calcium Channel Blockers amlodipine/valsartan EXFORGE amlodipine bes/olmesartan med AZOR Antihypertensives, ACE Inhibitors benazepril hcl LOTENSIN captopril CAPOTEN enalapril maleate VASOTEC fosinopril sodium MONOPRIL lisinopril PRINIVIL

ZESTRIL moexipril hcl UNIVASC quinapril hcl ACCUPRIL ramipril ALTACE trandolapril MAVIK Antihypertensives, Angiotensin Receptor Antagonists azilsartan

irbesartan EDARBI AVAPRO

losartan potassium COZAAR valsartan DIOVAN olmesartan medoxomil BENICAR Antihypertensives, Sympatholytic clonidine hcl CATAPRES guanfacine hcl TENEX methyldopa ALDOMET reserpine SERPASIL Antihypertensives, Vasodilators hydralazine hcl APRESOLINE Beta-Adrenergic Blocking Agents acebutolol hcl SECTRAL atenolol TENORMIN bisoprolol fumarate ZEBETA metoprolol succinate TOPROL XL metoprolol tartrate LOPRESSOR nadolol CORGARD pindolol VISKEN propranolol hcl INDERAL LA sotalol hcl BETAPACE

BETAPACE AF timolol maleate BLOCADREN nebivolol hcl BYSTOLIC Beta-Adrenergic Blocking Agents/Thiazide & Related atenolol/chlorthalidone TENORETIC 100

TENORETIC 50 bisoprolol fumarate/hctz ZIAC metoprolol/hctz LOPRESSOR HCT propranolol/hydrochlorothiazid INDERIDE-40/25 Calcium Channel Blocking Agents amlodipine besylate NORVASC diltiazem hcl CARDIZEM

CARDIZEM CD DILACOR XR TIAZAC

felodipine PLENDIL isradipine IR capsules ISRADIPINE nicardipine hcl NICARDIPINE nifedipine ADALAT CC

PROCARDIA PROCARDIA XL

nimodipine NIMOTOP verapamil hcl CALAN

VERELAN verapamil hcl ER CALAN SR

VERELAN PM Loop Diuretics bumetanide BUMEX furosemide LASIX torsemide DEMADEX Potassium Sparing Diuretics eplerenone INSPRA spironolactone ALDACTONE Potassium Sparing Diuretics in Combination triamterene/hydrochlorothiazid DYAZIDE

MAXZIDE MAXZIDE-25MG

Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors PA sildenafil citrate REVATIO TABLET PA tadalafil ADCIRCA Pulmonary Anti-HTN, Endothelin Receptor Antagonists PA ambrisentan LETAIRIS PA bosentan TRACLEER PA macitentan OPSUMIT Pulmonary Anti-HTN, Prostacyclin-Type PA selexipag UPTRAVI Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulator PA riociguat ADEMPAS Thiazide & Related Diuretics chlorthalidone HYGROTON hydrochlorothiazide MICROZIDE indapamide LOZOL metolazone ZAROXOLYN chlorthalidone THALITONE CARDIOVASCULAR DISEASE - LIPID IRREGULARITY Antihyperlipidemic - APO B-100 Synthesis Inhibitor PA mipomersen sodium KYNAMRO Antihyperlipidemic - HMG CoA Reductase Inhibitors atorvastatin calcium LIPITOR lovastatin MEVACOR QL pitavastatin LIVALO pravastatin sodium PRAVACHOL

ST simvastatin simvastatin (80mg only)

ZOCOR

QL rosuvastatin calcium CRESTOR Antihyperlipidemic - MTP Inhibitors

PA + QL

lomitapide JUXTAPID

Antihyperlipidemic – PCSK9 Inhibitors PA alirocumab PRALUENT PA evolocumab REPATHA Bile Salt Sequestrants cholestyramine/aspartame

cholestyramine/sucrose QUESTRAN LIGHT QUESTRAN

colesevelam hcl WELCHOL WELCHOL POWDER PACKETS

colestipol COLESTID COLESTID GRANULES

Lipotropics



fenofibrate FENOGLIDE LOFIBRA TABS

fenofibrate, micronized LOFIBRA CAPS fenofibrate nanocrystallized TRICOR gemfibrozil LOPID ST niacin NIASPAN QL omega-3 acid ethyl esters LOVAZA QL ezetimibe ZETIA fenofibrate TRIGLIDE QL icosapent ethyl VASCEPA Niacin Preparations niacin SLO-NIACIN CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS Adrenergic Vasopressor Agents midodrine hcl PROAMATINE Angiotensin Recept-Neprilysin Inhibitor Comb(ARNI) QL sacubitril/valsartan ENTRESTO Antianginal & Anti-Ischemic Agents, Non-Hemodynamic QL ranolazine RANEXA Antihyperlipidemic - HMG-CoA & Calcium Channel Blocker Combinations QL amlodipine/atorvastatin CADUET Heart Rate Reducing, Selective I(F) Current Inhib. PA +

QL ivabradine hcl CORLANOR

CARDIOVASCULAR DISEASE - VASODILATION Vasodilators, Combination isosorb dinit/hydralazine hcl BIDIL Vasodilators, Coronary isosorbide dinitrate ISOCHRON

ISORDIL ISORDIL TITRADOSE

isosorbide mononitrate IMDUR ISMO MONOKET

nitroglycerin transdermal patch NITRO-DUR nitroglycerin transdermal ointment

nitroglycerin sublingual solution nitroglycerin sublingual tablet

NITRO-BID NITROLINGUAL NITROSTAT

CONTRACEPTION/OXYTOCICS Contraceptives, Intravaginal, Systemic QL etonogestrel/ethinyl estradiol NUVARING Contraceptives, Oral desog-et estra/ethin estra MIRCETTE desogestrel-ethinyl estradiol CYCLESSA

DESOGEN ORTHO-CEPT

ST ST ST ST ST ST ST ST

ethinyl estradiol/drospirenone GIANVI LORYNA OCELLA SYEDA VESTURA YASMIN 28 YAZ ZARAH

ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 levonorgestrel AFTERA

PLAN B ONE-STEP TAKE ACTION

QL

levonorgestrel-eth estra NORDETTE-28 SEASONALE AVIANE-28 LESSINA LUTERA ORSYTHIA SRONYX

noreth a-et estra/fe fumarate LOESTRIN FE LOESTRIN 24FE

norethindrone NOR-Q-D ORTHO MICRONOR

norethindrone a-e estradiol LOESTRIN norethindrone-ethinyl estrad NORINYL 1+35

ORTHO-NOVUM TRI-NORINYL

norethindrone-mestranol NORINYL 1+50 norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN

ORTHO-CYCLEN norgestrel-ethinyl estradiol LO-OVRAL-28 norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO noreth a-et estra/fe fumarate LO LOESTRIN FE Contraceptives, Transdermal QL norelgestromin/ethin.estradiol ORTHO EVRA Oxytocics methylergonovine maleate METHERGINE COUGH AND COLD 1st Generation Antihistamine & Decongestant Combinations phenylephrine hcl/prometh hcl PHENERGAN VC Narcotic Antitussive-1st Generation Antihistamine-Decongestants phenylephrine hcl/cod/prometh PHENERGAN VC

W/CODEINE Narcotic Antitussive-1st Generation Antihistamines codeine/promethazine hcl PHENERGAN

W/CODEINE hydrocodone/chlorphen p-stirex TUSSIONEX Narcotic Antitussive-Anticholinergic Comb. hydrocodone/homatrop me-br HYCODAN Non-Narcotic Antitussive-1st Generation Antihistamine Combinations. d-methorphan hb/prometh hcl PHENERGAN W/

DEXTROMETHORPHAN DERMATOLOGY - ACNE Acne Agents, Systemic isotretinoin AMNESTEEM

CLARAVIS MYORISAN SOTRET ZENATANE

Acne Agents, Topical AGE adapalene/benzoyl peroxide

clindamycin phos/benzoyl peroxide

EPIDUO, EPIDUO FORTE ONEXTON

clindamycin/Tretinoin sulfacetamide sodium

ZIANA KLARON

Keratolytic-Glucocorticoid Combinations benzoyl peroxide/hydrocortison VANOXIDE-HC Keratolytics benzoyl peroxide BREVOXYL-4

BREVOXYL-8 TRIAZ

podofilox CONDYLOX Rosacea Agents, Topical metronidazole METROCREAM

METROLOTION Vitamin A Derivatives AGE adapalene DIFFERIN AGE tazarotene FABIOR DERMATOLOGY - ANTIINFECTIVE Topical Antibiotics clindamycin phosphate CLEOCIN T erythromycin base/benz per BENZAMYCIN erythromycin base/ethanol EMGEL

ERYGEL gentamicin sulfate GARAMYCIN mupirocin BACTROBAN

CENTANY clindamycin phosphate EVOCLIN erythromycin base/benz per BENZAMYCIN PAK mupirocin calcium BACTROBAN Topical Antifungals



ciclopirox olamine LOPROX ciclopirox 8% solution CICLODAN clotrimazole/betamet diprop LOTRISONE ketoconazole KURIC

NIZORAL naftifine hcl 1% cream NAFTIN naftifine hcl 1% gel, 2%

cream/gel NAFTIN

nystatin MYCOSTATIN nystatin/triamcin MYCOLOG II sulconazole nitrate EXELDERM terbinafine hcl LAMISIL Topical Antiparasitics lindane KWELL malathion OVIDE permethrin ELIMITE crotamiton EURAX Topical Antivirals acyclovir ZOVIRAX OINTMENT acyclovir ZOVIRAX CREAM Topical Sulfonamides silver sulfadiazine SILVADENE

THERMAZENE DERMATOLOGY - ANTIINFLAMMATORY Topical Anti-Inflammatory Steroidal alclometasone dipropionate ACLOVATE amcinonide CYCLOCORT betamet diprop/prop gly DIPROLENE

DIPROLENE AF betamethasone dipropionate DEL-BETA

DIPROSONE betamethasone valerate VALISONE clobetasol propionate CLOBEX clobetasol propionate OLUX

TEMOVATE clobetasol propionate/emoll TEMOVATE EMOLLIENT desonide DESOWEN

TRIDESILON desoximetasone TOPICORT (CREAM,

GEL, OINTMENT) TOPICORT LP

diflorasone diacetate APEXICON fluocinolone acetonide SYNALAR fluocinonide LIDEX

VANOS fluocinonide/emollient LIDEX-E fluticasone propionate CUTIVATE halobetasol propionate ULTRAVATE hydrocortisone LACTICARE-HC

REDERM SCALACORT

hydrocortisone acetate/urea CARMOL HC hydrocortisone butyrate LOCOID hydrocortisone valerate WESTCORT mometasone furoate ELOCON triamcinolone acetonide KENALOG

TRIDERM diflorasone diacetate/emoll APEXICON E flurandrenolide CORDRAN

CORDRAN SP hydrocort/sal acid/sulf/shmp#1 SCALACORT DK hydrocortisone TEXACORT hydrocortisone butyrate/emoll LOCOID LIPOCREAM hydrocortisone probutate PANDEL Topical Anti-Inflammatory, NSAIDs diclofenac sodium VOLTAREN GEL Topical Antibiotics/Antiinflammatory, Steroidal neomy sulf/polymyx b sulf/hc CORTISPORIN CREAM neomycin/bacitra/polymyxin/hc CORTISPORIN OINT

DERMATOLOGY - MISCELLANEOUS Antiperspirants aluminum chloride DRYSOL Antiseborrheic Agents selenium sulfide SELSUN RX sulfacetamide sodium OVACE PLUS

SUSPENSION Topical Antineoplastic & Premalignant Lesion Agents fluorouracil EFUDEX PA bexarotene TARGRETIN QL ingenol PICATO PA mechlorethamine gel VALCHLOR Topical Local Anesthetics hc acetate/pramoxine PRAMOSONE DERMATOLOGY - PIGMENTATION DISORDERS Topical Hyperpigmentation Agents methoxsalen OXSORALEN DERMATOLOGY - PSORIASIS/ECZEMA Antipsoriatic Agents, Systemic

PA acitretin apremilast

SORIATANE OTEZLA

methoxsalen, rapid OXSORALEN-ULTRA methoxsalen 8-MOP PA secukinumab COSENTYX Antipsoriatics Agents calcipotriene DOVONEX anthralin DRITHO-SCALP anthralin DRITHOCREME HP tazarotene TAZORAC Topical Immunosuppressive Agents tacrolimus

pimecrolimus PROTOPIC ELIDEL

Topical Phosphodiesterase (PDE-4) Inhibitor

crisaborole EUCRISA

DIABETES Antihyperglycemics, Incretin Mimetics (GLP-1 Receptor Agonists) QL dulaglutide TRULICITY QL liraglutide VICTOZA Antihyperglycemics, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) acarbose PRECOSE Antihyperglycemics, Amylin Analog-Type pramlintide acetate SYMLIN

SYMLINPEN 120 SYMLINPEN 60

Antihyperglycemics, DPP-4 Inhibitors QL linagliptin TRADJENTA QL sitagliptin phosphate JANUVIA Antihyperglycemics, (DPP-4) Inhibitor & Biguanide Combinations QL linagliptin/metformin hcl JENTADUETO QL

QL sitagliptin phos/metformin hcl JANUMET

JANUMET XR Antihyperglycemics, Insulin-Release Stimulant Type chlorpropamide DIABINESE glimepiride AMARYL glipizide GLUCOTROL

GLUCOTROL XL glipizide/metformin hcl METAGLIP glyburide DIABETA

MICRONASE nateglinide STARLIX repaglinide PRANDIN tolazamide TOLINASE tolbutamide ORINASE Antihyperglycemic, Insulin-Response Enhancers (Non-



Sulfonylurea) pioglitazone hcl ACTOS Antihyperglycemics, Biguanide Type (Non-Sulfonylurea) metformin hcl GLUCOPHAGE

GLUCOPHAGE XR metformin hcl RIOMET Antihyperglycemics, Insulin-Rel Stim. & Biguanide Combinations glyburide, micro/metformin hcl GLUCOVANCE repaglinide/metformin hcl PRANDIMET Antihyperglycemic, Insulin-Response & Release Combinationsination pioglitazone/glimepiride DUETACT Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations pioglitazone hcl/metformin hcl

ACTOPLUS MET ACTOPLUS MET XR

Antihyperglycemic-Glucocorticoid Receptor Blocker PA mifepristone KORLYM Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors QL canagliflozin INVOKANA QL empagliflozin JARDIANCE Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Biguanide Combination QL canagliflozin/metformin hcl INVOKAMET QL canagliflozin/metformin hcl XR INVOKAMET XR QL

QL empagliflozin/metformin hcl empagliflozin/metformin XR

SYNJARDY SYNJARDY XR

Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination QL empagliflozin/linagliptin GLYXAMBI Diabetic Supplies blood glucose calib. control ABBOTT CONTROL

PRODUCTS (e.g., FREESTYLE, PRECISION)

blood-glucose meter ABBOTT METERS (e.g., FREESTYLE, PRECISION)

blood sugar diagnostics ABBOTT TEST STRIPS (e.g., FREESTYLE, PRECISION)

lancing device/lancets ABBOTT PRODUCTS

Diabetic Ulcer Preparations, Topical becaplermin REGRANEX Hyperglycemics glucagon,human recombinant GLUCAGON

EMERGENCY KIT Insulins QL

QL insulin glargine,hum.rec.anlog LANTUS

TOUJEO QL insulin lispro HUMALOG QL insulin nph hum/reg insulin hm HUMULIN 70-30 QL insulin nph human isophane HUMULIN N QL

QL insulin npl/insulin lispro HUMALOG MIX 50-50

HUMALOG MIX 75-25 QL insulin regular, human HUMULIN R QL insulin regular, human HUMULIN R U-500 KWIK

PEN Syringes & Accessories syringes & needles ALL COMMERCIALLY

AVAILABLE SYRINGES AND NEEDLES

EAR - GENERAL DISORDERS Ear Preparations, Miscellaneous Anti-Infectives acetic acid VOSOL acetic acid/aluminum acetate DOMEBORO acetic acid/hydrocortisone VOSOL HC

Ear Preparations, Antibiotics neomy sulf/polymyx b sulf/hc CORTISPORIN OTIC

OTICIN HC ofloxacin FLOXIN Otic Preparations, Anti-Inflammatory-Antibiotics ciprofloxacin hcl/dexameth CIPRODEX Otic Preparations, Local Anesthetics antipyrine/benzocaine otic BENZOTIC ELECTROLYTE REGULATION Electrolyte Depleters calcium acetate PHOSLO sodium polystyrene sulfonate KAYEXALATE sevelamer carbonate RENVELA sevelamer hcl RENAGEL Potassium Replacement potassium chloride K-DUR

K-TAB MICRO-K

ENDOCRINE DISORDER - FERTILITY Drugs to Treat Impotency QL sildenafil citrate VIAGRA Fertility Stimulating Preparations, Non-FSH clomiphene citrate CLOMID

SEROPHENE Follicle Stimulating/Luteinizing Hormones follitropin alpha, recomb GONAL-F

GONAL-F RFF gonadotropin,chorionic, human NOVAREL

PREGNYL PROFASI

hcg alpha, recombinant OVIDREL menotropins MENOPUR

REPRONEX Pregnancy Facilitating/Maintaining Agents, Hormonal progesterone, micronized CRINONE

ENDOMETRIN PROCHIEVE

ENDOCRINE DISORDER - OTHER Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants PA leuprolide ELIGARD Antidiuretic & Vasopressor Hormones desmopressin (nonrefrigerated) DDAVP Bone Formation Stim. Agents - Parathyroid Hormone QL teriparatide FORTEO Bone Resorption Inhibitor & Vitamin D Combinations alendronate sodium/vitamin d3 FOSAMAX PLUS D Bone Resorption Inhibitors alendronate sodium tablet FOSAMAX TABLET QL alendronate sodium solution FOSAMAX SOLUTION etidronate disodium DIDRONEL ibandronate BONIVA QL raloxifene hcl EVISTA Growth Hormone Receptor Antagonists pegvisomant SOMAVERT Growth Hormones PA somatropin NORDITROPIN NORDITROPIN

FLEXPRO NORDITROPIN

NORDIFLEX PA somatropin OMNITROPE Hyperparathyroid Tx Agents, Vitamin D Analog-Type QL calcifediol

paricalcitol RAYALDEE ZEMPLAR

LHRH (GnRH) Antagonist, Pituitary Suppressant Agents cetrorelix acetate CETROTIDE ganirelix acetate GANIRELIX ACETATE Luteinizing Hormone Releasing Hormone –LHRH (GnRH)



Pituitary Suppressive Agents cabergoline DOSTINEX danazol DANOCRINE ENDOCRINE DISORDER - THYROID Antithyroid Preparations methimazole TAPAZOLE propylthiouracil PROPYLTHIOURACIL Iodine Containing Agents potassium iodide POTASSIUM IODIDE Thyroid Hormones levothyroxine sodium LEVOTHROID

LEVOXYL SYNTHROID

liothyronine sodium CYTOMEL thyroid, pork

ARMOUR THYROID NATURE-THROID WESTHROID

EYE - GENERAL DISORDERS Eye Antibiotic-Corticoid Combinations neo/polymyx b sulf/dexameth MAXITROL neomy sulf/bacitrac zn/poly/hc NEO-POLYCIN HC

OPHTH OINTMENT neomy sulf/polymyx b sulf/hc CORTISPORIN OPHTH

SUSPENSION tobramycin sulfate/dexameth TOBRADEX tobramycin/lotepred etab ZYLET Eye Antihistamines azelastine hcl OPTIVAR ketotifen fumarate (OTC) ALAWAY (OTC) QL olopatadine hcl

PATADAY PATANOL

Eye Antiinflammatory Agents diclofenac sodium VOLTAREN fluorometholone FML flurbiprofen sodium OCUFEN ketorolac tromethamine ACULAR

ACULAR LS prednisolone acetate OMNIPRED

PRED FORTE prednisolone sod phosphate PREDNISOL difluprednate DUREZOL fluorometholone FML FORTE

FML S.O.P. fluorometholone acetate FLAREX loteprednol etabonate ALREX

LOTEMAX nepafenac ILEVRO

NEVANAC prednisolone acetate PRED MILD Eye Antivirals trifluridine VIROPTIC ganciclovir ZIRGAN Eye Sulfonamides na sulfacetm/prednis sp VASOCIDIN sulfacetamide sodium SULFAC na sulfacetm/prednisol ac BLEPHAMIDE

BLEPHAMIDE S.O.P. EYE - MISCELLANEOUS Ophthalmic Cystine Delpleting Agents PA cysteamine CYSTARAN Ophthalmic Anti-Inflammatory Immunomodulator-Type QL

QL

cyclosporine RESTASIS SINGLE DOSE RESTASIS MULTIDOSE

QL lifitegrast XIIDRA Ophthalmic Antibiotics bacitracin AK-TRACIN bacitracin/polymyxin b sulfate POLYCIN-B ciprofloxacin hcl CILOXAN

erythromycin base ROMYCIN gatifloxacin ZYMAXID gentamicin sulfate GARAMYCIN neomycin/bacitracin/polymyxin NEOSPORIN OPHTH

OINTMENT neomycin/polymyxn

b/gramicidin NEOSPORIN OPHTH DROPS

ofloxacin OCUFLOX polymyxin b sulfate/tmp POLYTRIM tobramycin sulfate TOBREX besifloxacin hcl drops susp 0.6% BESIVANCE moxifloxacin hcl VIGAMOX Ophthalmic Mast Cell Stabilizers cromolyn sodium OPTICROM lodoxamide tromethamine ALOMIDE nedocromil sodium ALOCRIL pemirolast potassium ALAMAST EYE - GLAUCOMA Carbonic Anhydrase Inhibitors acetazolamide DIAMOX SEQUELS methazolamide NEPTAZANE Miotics/Other Intraocular Pressure Reducers betaxolol hcl BETOPTIC QL bimatoprost 0.03% LUMIGAN brimonidine tartrate ALPHAGAN P carteolol hcl OCUPRESS dorzolamide hcl TRUSOPT dorzolamide hcl/timolol maleat COSOPT latanoprost XALATAN levobunolol hcl BETAGAN metipranolol OPTIPRANOLOL pilocarpine hcl ISOPTO CARPINE timolol maleate

TIMOPTIC (except Ocudose) TIMOPTIC-XE

QL travoprost (benzalkonium) TRAVATAN betaxolol hcl BETOPTIC S QL bimatoprost 0.01% LUMIGAN brimonidine/timolol COMBIGAN brinzolamide AZOPT brinzolamide/brimonidine SIMBRINZA carbachol ISOPTO CARBACHOL timolol BETIMOL QL travoprost TRAVATAN Z Mydriatics atropine sulfate ISOPTO ATROPINE cyclopentolate hcl CYCLOGYL homatropine hbr ISOPTO HOMATROPINE dipivefrin hcl PROPINE Hyperuricemia Treatments - Purine Inhibitors allopurinol ZYLOPRIM QL febuxostat ULORIC Uricosuric Agents QL lesinurad ZURAMPIC probenecid BENEMID HEMATOLOGICAL DISORDERS Anticoagulants, Coumarin Type warfarin sodium COUMADIN Direct Factor XA Inhibitors QL apixaban ELIQUIS QL rivaroxaban XARELTO Hematinics, Other PA epoetin alfa PROCRIT Hemorrheologic Agents pentoxifylline TRENTAL Heparin & Related Preparations QL enoxaparin sodium LOVENOX



QL fondaparinux sodium ARIXTRA heparin sodium, porcine HEP-LOCK

HEPARIN LOCK heparin sodium, porcine/pf HEP-LOCK QL dalteparin sodium, porcine FRAGMIN Leukocyte (WBC) Stimulants PA filgrastim NEUPOGEN PA pegfilgrastim NEULASTA PA sargramostim LEUKINE Platelet Aggregation Inhibitors cilostazol PLETAL clopidogrel bisulfate 75mg PLAVIX 75MG QL clopidogrel bisulfate 300mg PLAVIX 300MG dipyridamole PERSANTINE QL prasugrel hcl EFFIENT QL ticagrelor BRILINTA Platelet Reducing Agents anagrelide hcl AGRYLIN Thrombopoietin Receptor Agonists PA +

QL eltrombopag olamine PROMACTA

Vitamin K Preparations phytonadione MEPHYTON HORMONAL DEFICIENCY Androgenic Agents QL fluoxymesterone ANDROXY methyltestosterone ANDROID PA testosterone 1% ANDROGEL PA +

QL testosterone cypionate DEPO-TESTOSTERONE

PA testosterone enantate DELATESTRYL methyltestosterone

METHITEST PA testosterone gel 1.62% ANDROGEL PA testosterone solution AXIRON Estrogen/Androgen Combinations estrogen, ester/me-testosterone ESTRATEST H.S. Estrogenic Agents

QL

estradiol CLIMARA ESTRACE VIVELLE-DOT

estropipate OGEN norethindrone ac-eth estradiol FEMHRT

estradiol ALORA

ESTRADERM QL estradiol/noreth ac COMBIPATCH estrogens, conj/bazedoxifene DUAVEE estrogen, con/m-progest acet PREMPHASE

PREMPRO estrogens, conjugated PREMARIN estrogens, esterified MENEST Progestational Agents medroxyprogesterone acet PROVERA norethindrone acetate AYGESTIN progesterone, micronized PROMETRIUM IMMUNOSUPPRESSION/MODULATION Immunomodulators PA +

QL imiquimod ALDARA

PA interferon alfa-2b, recomb. INTRON A Immunosuppressives azathioprine IMURAN cyclosporine SANDIMMUNE cyclosporine, modified NEORAL mycophenolate mofetil CELLCEPT sirolimus RAPAMUNE tacrolimus anhydrous PROGRAF everolimus ZORTRESS

INFECTIOUS DISEASE - BACTERIAL Absorbable Sulfonamides sulfadiazine SULFADIAZINE sulfamethoxazole/trimethoprim BACTRIM DS

SEPTRA SEPTRA DS

sulfisoxazole acetyl GANTRISIN Betalactams PA aztreonam lysine CAYSTON Cephalosporins - 1st Generation cefadroxil hydrate DURICEF cephalexin monohydrate KEFLEX Cephalosporins - 2nd Generation cefaclor CECLOR cefprozil CEFZIL cefuroxime axetil CEFTIN Cephalosporins - 3rd Generation cefdinir OMNICEF cefixime SUPRAX cefpodoxime proxetil VANTIN Chemotherapeutics, Antibacterial, Miscellaneous. trimethoprim PROLOPRIM meth/meth blue/ba/salicy/hyos PROSED-DS mth/me blue/salicy/na phos/hyo URETRON D-S

URIN D.S. trimethoprim PRIMSOL Ketolides telithromycin KETEK Lincosamides clindamycin palmitate solution CLEOCIN PALMITATE clindamycin hcl capsules CLEOCIN HCL Macrolides azithromycin ZITHROMAX

ZITHROMAX TRI-PAK clarithromycin BIAXIN

BIAXIN XL ery e-succ/sulfisoxazole PEDIAZOLE erythromycin base ERYC erythromycin ethylsuccinate ERYPED 200 erythromycin stearate ERYTHROCIN

STEARATE azithromycin ZMAX

ZMAX PEDIATRIC erythromycin base ERY-TAB

PCE erythromycin ethylsuccinate ERYPED 200

ERYPED 400 QL fidaxomicin DIFICID Nitrofuran Derivatives nitrofurantoin macrocrystal MACRODANTIN nitrofurantoin/nitrofuran mac MACROBID furazolidone FUROXONE nitrofurantoin FURADANTIN Oxazolidinones PA linezolid ZYVOX PA tedizolid phosphate tablet SIVEXTRO TABLET Penicillins amox tr/potassium clavulanate AUGMENTIN

AUGMENTIN ES-600 AUGMENTIN XR

amoxicillin trihydrate AMOXIL ampicillin trihydrate POLYCILLIN dicloxacillin sodium PATHOCIL penicillin v potassium V-CILLIN K Quinolones ciprofloxacin CIPRO ORAL

SUSPENSION ciprofloxacin hcl CIPRO



levofloxacin LEVAQUIN moxifloxacin hcl AVELOX

AVELOX ABC PACK ofloxacin FLOXIN Tetracyclines QL

doxycycline hyclate

VIBRAMYCIN 100MG CAPSULE

QL QL

MORGIDOX 50MG CAPSULE MORGIDOX 100MG CAPSULE

QL doxycycline monohydrate DOXYCYCLINE MONOHYDRATE 150MG TABLET

minocycline hcl DYNACIN MINOCIN

tetracycline hcl ALA-TET doxycycline calcium VIBRAMYCIN SYRUP INFECTIOUS DISEASE - FUNGAL Antifungal Agents clotrimazole MYCELEX fluconazole DIFLUCAN itraconazole SPORANOX ketoconazole NIZORAL terbinafine hcl LAMISIL voriconazole VFEND terbinafine hcl LAMISIL GRANULES Antifungal Antibiotics griseofulvin ultramicrosize GRIS-PEG nystatin MYCOSTATIN griseofulvin suspension GRISEOFULVIN INFECTIOUS DISEASE - MISCELLANEOUS Aminoglycosides neomycin sulfate MYCIFRADIN PA tobramycin in 0.225% nacl TOBI PA tobramycin TOBI PODHALER Anti-Mycobacterium Agents ethambutol hcl MYAMBUTOL isoniazid NYDRAZID pyrazinamide PYRAZINAMIDE Antileprotics dapsone AVLOSULFON PA thalidomide THALOMID Antitubercular Antibiotics rifampin RIFADIN rifampin/isoniazid RIFAMATE Rifamycins and Related Derivative Antibiotics PA rifaximin XIFAXAN 550MG Vancomycin & Derivatives QL vancomycin hcl VANCOCIN INFECTIOUS DISEASE - PARASITIC Amebacides paromomycin sulfate HUMATIN iodoquinol YODOXIN Anaerobic Antiprotozoal-Antibacterial Agents metronidazole FLAGYL metronidazole FLAGYL ER Anthelmintics praziquantel BILTRICIDE PA mebendazole EMVERM Antimalarial Drugs chloroquine phosphate ARALEN PHOSPHATE hydroxychloroquine sulfate PLAQUENIL mefloquine hcl LARIAM quinine sulfate QUALAQUIN primaquine phosphate PRIMAQUINE PA pyrimethamine DARAPRIM

Antiprotozoal Drugs, Miscellaneous PA miltefoside IMPAVIDO pentamidine isethionate NEBUPENT INFECTIOUS DISEASE - VIRAL All oral, non-experimental antiviral agents used for the treatment of AIDS or HIV-related diseases are considered a formulary benefit Antiretroviral Combination, Integrase Inhibitors QL abacavir/dolutegravir/lamivudine TRIUMEQ QL elvitegravir/cobicistat/emtricitabine/

tenofovir disoproxil fumarate STRIBILD

QL elviteg/cobi/emtric/tenofo ala GENVOYA Antivirals, General acyclovir ZOVIRAX ganciclovir CYTOVENE valacyclovir hcl VALTREX QL oseltamivir phosphate TAMIFLU ribavirin VIRAZOLE Antivirals, HIV-Spec, Non-Peptidic Protease Inhibitors QL darunavir ethanolate PREZISTA QL darunavir/cobicistat PREZCOBIX QL tipranavir APTIVUS CAPS QL tipranavir/vitamin e tpgs APTIVUS SOLN Antivirals, HIV-Spec, Nucleoside-Nucleotide Analogs QL emtricitabine/tenofov alafenam DESCOVY QL emtricitabine/tenofovir TRUVADA Antivirals, HIV-Spec, Nucleoside Analog, RTI Combinations QL abacavir/lamivudine/zidovudine TRIZIVIR QL abacavir sulfate/lamivudine EPZICOM QL lamivudine/zidovudine COMBIVIR Antivirals, HIV-Specific, CCR5 Co-Receptor Antagonists QL maraviroc SELZENTRY Antivirals, HIV-Specific, Fusion Inhibitors QL enfuvirtide FUZEON Antivirals, HIV-Specific, Non-Nucleoside, RTI QL nevirapine VIRAMUNE QL nevirapine ER VIRAMUNE XR delavirdine mesylate RESCRIPTOR efavirenz SUSTIVA QL etravirine INTELENCE QL rilpivirine EDURANT Antivirals, HIV-Specific, Nucleoside Analog, RTI QL abacavir sulfate ZIAGEN QL didanosine VIDEX EC QL lamivudine EPIVIR QL stavudine ZERIT QL zidovudine RETROVIR QL didanosine VIDEX SOLUTION QL emtricitabine EMTRIVA Antivirals, HIV-Specific, Nucleotide Analog, RTI QL tenofovir disoproxil fumarate VIREAD Antivirals, HIV-Specific, Protease Inhibitor Combinations QL lopinavir/ritonavir KALETRA Antivirals, HIV-Specific, Protease Inhibitors QL atazanavir sulfate REYATAZ QL atazanavir sulfate/cobicistat EVOTAZ QL fosamprenavir calcium LEXIVA indinavir sulfate CRIXIVAN nelfinavir mesylate VIRACEPT QL ritonavir NORVIR QL saquinavir mesylate INVIRASE Antivirals, HIV-1 Integrase Strand Transfer Inhibitors QL dolutegravir TIVICAY QL raltegravir potassium ISENTRESS Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI QL efavirenz/emtricitab/tenofovir ATRIPLA



QL rilpivirine/ emtricitabine/ tenofovir disoproxil fumarate

COMPLERA

QL emtricitab/rilpiviri/tenof ala ODEFSEY Cytochrome P450 Inhibitors QL cobicistat TYBOST Hepatitis B Treatment Agents QL adefovir dipivoxil HEPSERA QL entecavir BARACLUDE QL lamivudine EPIVIR HBV TABLET QL lamivudine EPIVIR HBV SOLUTION telbivudine TYZEKA Hepatitis C Combination Agents PA ledipasvir/sofosbuvir HARVONI PA sofosbuvir/velpatasvir EPCLUSA Hepatitis C Treatment Agents ribavirin 200mg COPEGUS

REBETOL CAPSULE PA

PA peginterferon alfa-2a peginterferon alfa-2a

PEGASYS PEGASYS PROCLICK

ribavirin REBETOL SOLUTION INFLAMMATORY DISEASE Anti-Arthritic & Chelating Agents penicillamine DEPEN Anti-Arthritic, Folate Antagonist Agents methotrexate sodium RHEUMATREX QL methotrexate OTREXUP Anti-Inflammatory Tumor Necrosis Factor Inhibitors PA adalimumab HUMIRA PA etanercept ENBREL Anti-Inflammatory, Pyrimidine Synthesis Inhibitors leflunomide ARAVA Bradykinin B2 Receptor Antagonists

PA icatibant acetate FIRAZYR

Glucocorticoids budesonide BUDESONIDE cortisone acetate CORTONE ACETATE dexamethasone tablet, elixir DECADRON hydrocortisone CORTEF methylprednisolone MEDROL prednisolone MILLIPRED

MILLIPRED DP prednisolone sod phosphate ORAPRED

PEDIAPRED prednisone DELTASONE

PREDNISONE INTENSOL

budesonide ENTOCORT EC Mineralocorticoids fludrocortisone acetate FLORINEF ACETATE Monoclonal antibody-human interleukin PA ustekinumab STELARA SC NSAIDs, Cyclooxygenase Inhibitor-Type celecoxib CELEBREX diclofenac sodium VOLTAREN

VOLTAREN-XR etodolac LODINE fenoprofen calcium NALFON TABLETS flurbiprofen ANSAID

ibuprofen MOTRIN indomethacin INDOCIN

INDOCIN SR ketoprofen ORUVAIL QL ketorolac tromethamine TORADOL meclofenamate sodium MECLOMEN meloxicam MOBIC nabumetone RELAFEN naproxen EC-NAPROSYN

NAPROSYN naproxen sodium ANAPROX

ANAPROX DS oxaprozin DAYPRO piroxicam FELDENE sulindac CLINORIL tolmetin sodium TOLECTIN 600 fenoprofen calcium NALFON CAPSULES indomethacin INDOCIN SUPPOS.

INDOCIN ORAL SUSP. LOCAL ANESTHESIA Local Anesthetics lidocaine hcl XYLOCAINE LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY Bowel Antiinflamatory Agents sulfasalazine AZULFIDINE Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx mesalamine SFROWASA mesalamine w/cleansing wipes ROWASA mesalamine CANASA Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat balsalazide disodium COLAZAL mesalamine APRISO

LIALDA PENTASA

Hemorrhoidal Preparations hc acetate/pramoxine hcl ANALPRAM HC Irritable Bowel Agents, Guanylate Cylase-C Agonists QL linaclotide LINZESS Rectal Preparations hydrocortisone PROCTO-KIT

PROCTOCORT CREAM PROCTOCREAM-HC

hydrocortisone acetate ANUSOL-HC PROCTOCORT SUPPOS.

hc acetate/pramoxine hcl PROCTOFOAM-HC Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) hydrocortisone CORTENEMA LOWER GASTROINTESTINAL DISORDERS - OTHER Ammonia Inhibitors lactulose CHRONULAC sodium phenylbutyrate BUPHENYL POWDER sodium phenylbutyrate BUPHENYL TABLET Antidiarrheals

diphenoxylate hcl/atrop sulf

LOMOTIL

Bile Salts ursodiol ACTIGALL

URSO URSO FORTE

Laxatives & Cathartics peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR

PACKETS polyethylene glycol 3350 MIRALAX sod chloride/nahco3/kcl/peg's NULYTELY WITH

FLAVOR PACKS lactulose KRISTALOSE peg 3350/na sulf,bicarb,cl/kcl GOLYTELY

OCL Narcotic Antagonists, Peripherally-Acting QL naloxegol oxalate MOVANTIK Tryptophan Hydroxylase Inhibitor PA telotristat XERMELO Glucagon-Like Peptide (GLP-2) Analogs QL teduglutide [rDNA origin] GATTEX MISCELLANEOUS AGENTS Anaphylaxis Therapy Agents epinephrine EPIPEN



epinephrine EPIPEN JR Parasympathetic Agents bethanechol chloride URECHOLINE cevimeline hcl EVOXAC pilocarpine hcl SALAGEN Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase PA sapropterin dihydrochloride KUVAN NEOPLASTIC DISEASE Alkylating Agents cyclophosphamide CYTOXAN hydroxyurea HYDREA lomustine CEENU PA temozolomide TEMODAR altretamine HEXALEN busulfan MYLERAN chlorambucil LEUKERAN melphalan ALKERAN Antiandrogenic Agents bicalutamide CASODEX flutamide EULEXIN PA abiraterone acetate ZYTIGA PA enzalutamide XTANDI QL nilutamide NILANDRON Antimetabolites PA capecitabine XELODA mercaptopurine PURINETHOL methotrexate sodium METHOTREXATE

TABLET methotrexate sodium METHOTREXATE VIAL thioguanine THIOGUANINE fludarabine phosphate OFORTA mercaptopurine PURIXAN methotrexate sodium TREXALL PA trifluridine/tipiracil hcl LONSURF Antineoplastic - Aromatase Inhibitors anastrozole ARIMIDEX exemestane AROMASIN letrozole FEMARA Antineoplastic – B Cell Lymphoma 2(BCL-2) Inhibitors PA venetoclax VENCLEXTA Antineoplastic – Hedgehog Pathway Inhibitors PA vismodegib ERIVEDGE PA sonidegib phosphate ODOMZO Antineoplastic – Janus Kinase (JAK) Inhibitors PA ruxolitinib JAKAFI PA tofacitinib XELJANZ PA tofacitinib XR XELJANZ XR PA ruxolitinib JAKAFI Antineoplastic – MEK1 and MEK2 Kinase Inhibitors PA +

QL cobimetinib fumarate COTELLIC

Antineoplastic - Topoisomerase I Inhibitors topotecan hcl HYCAMTIN Antineoplastic - Immunomodulator Agents PA +

QL lenalidomide REVLIMID

PA pomalidamide POMALYST Antineoplastic - Systemic Enzyme Inhibitors PA afatinib GILOTRIF PA +

QL alectinib hydrochloride ALECENSA

PA+ QL PA

axitinib bosutinib

INLYTA BOSULIF

PA cabozanitinib COMETRIQ PA cabozantinib s-malate CABOMETYX PA ceritinib ZYKADIA PA crizotinib XALKORI

QL PA dabrafanib TAFINLAR PA dasatinib SPRYCEL PA+

QL erlotinib hcl TARCEVA

PA gefitinib IRESSA PA ibrutinib IMBRUVICA PA

PA idelalisib imatinib mesylate

ZYDELIG GLEEVEC

PA ixazomib citrate NINLARO PA lapatinib ditosylate TYKERB PA lenvatinib mesylate LENVIMA PA nilotinib hydrochloride TASIGNA PA olaparib LYNPARZA PA +

QL osimertinib mesylate TAGRISSO

PA pazopanib hydrochloride VOTRIENT PA palbociclib IBRANCE PA ponatinib ICLUSIG PA

PA regorafenib ribociclib succinate

STIVARGA KISQALI

PA sorafenib tosylate NEXAVAR PA sunitinib malate SUTENT PA trametinib dimethyl sulfoxide MEKINIST PA vemurafenib

ZELBORAF

Antineoplastic, Histone Deacetylase Inhibitors, HDIS PA panobinostat lactate FARYDAK vorinostat ZOLINZA Antineoplastics, Miscellaneous etoposide VEPESID mitotane LYSODREN procarbazine hcl MATULANE tretinoin VESANOID Antineoplastic mTOR Kinase Inhibitors PA

QL PA

everolimus AFINITOR AFINITOR DISPERZ

Chemotherapy Rescue/Antidote Agents leucovorin calcium LEUCOVORIN CALCIUM QL vridine triacetate VISTOGARD Selective Estrogen Receptor Modulators (SERM) tamoxifen citrate NOLVADEX PA toremifene citrate FARESTON Selective Retinoid X Receptor Agonists (RXR) PA bexarotene TARGRETIN Steroid Antineoplastics megestrol acetate MEGACE estramustine phosphate sodium EMCYT NEUROLOGICAL DISEASE - MISCELLANEOUS Agents to Treat Multiple Sclerosis PA glatiramer acetate COPAXONE PA dimethyl fumarate TECFIDERA PA fingolimod hcl GILENYA PA interferon beta-1a AVONEX PA

PA PA

interferon beta-1a/albumin

AVONEX ADMINISTRATION PACK REBIF REBIF REBIDOSE

PA PA PA

peginterferon beta-1a teriflunomide

PLEGRIDY PLEGRIDY PEN AUBAGIO

Fibromyalgia Agents, Serotonin-Norepinephrine Reuptake Inhibitors milnacipran hcl SAVELLA Movement Disorders (Drug Therapy) PA tetrabenazine XENAZINE ORAL/PHARYNGEAL DISORDERS



Dental Aids & Preparations chlorhexidine gluconate PERIDEX triamcinolone acetonide KENALOG IN ORABASE Nose Preparations, Antibiotics mupirocin calcium BACTROBAN NASAL Nose Preparations, Miscellaneous (Rx) ipratropium bromide ATROVENT OTHER DRUGS Appetite Stim. For Anorexia, Cachexia, Wasting Synd. megestrol acetate MEGACE

MEGACE ES General Inhalation Agents sodium chloride for inhalation HYPER-SAL 7% Metabolic disease enzyme replace, hypophosphatasia PA asfotase alfa STRENSIQ Needles/Needleless Devices needles, insulin disp., safety PEN NEEDLE Nucleic Acid/Nucleotide Supplements PA uridine triacetate XURIDEN Somatostatic Agents octreotide acetate SANDOSTATIN Drugs to treat hereditary tyrosinemia PA nitisinone ORFADIN OTHER RESPIRATORY DISORDERS Antifibrotic Therapy – Pyridone Analogs PA pirfenidone ESBRIET Cystic Fibrosis-Cftr Potentiator & Corrector Comb. PA lumacaftor/ivacaftor ORKAMBI Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiator PA ivacaftor KALYDECO Mucolytics acetylcysteine MUCOMYST-10 PA dornase alfa PULMOZYME Pulmonary Fibrosis – Systemic Enzyme Inhibitors PA nintedanib esylate OFEV PAIN MANAGEMENT - ANALGESICS Analgesic, Non-Salicylate & Barbiturate Combinations. butalbital/acetaminophen PHRENILIN butalbital/acetaminophen PHRENILIN FORTE Analgesic, Salicylate, Barbiturate & Xanthine Comb butalbital/aspirin/caffeine FIORINAL Analgesic, Non-Salicylate, Barbiturate & Xanthine Comb butalb/acetaminophen/caffeine ESGIC

FIORICET Analgesic/Antipyretics, Salicylates diflunisal DOLOBID salsalate DISALCID Analgesics, Narcotics codeine phos/carisoprodol/asa SOMA COMPOUND

WITH CODEINE PA fentanyl DURAGESIC PA fentanyl citrate lozenge ACTIQ QL hydrocodone bit/acetaminophen

(300mg) VICODIN VICODIN ES VICODIN HP

QL hydrocodone bit/acetaminophen (325mg)

LORCET LORCET PLUS LORTAB NORCO

QL hydrocodone bit/acetaminophen oral elixir (300mg/15ml)

LORTAB ELIXIR

hydromorphone hcl DILAUDID methadone hcl DOLOPHINE HCL QL+

ST methadone hcl injection solution METHADONE HCL

INJECTION SOLUTION QL morphine sulfate AVINZA QL morphine sulfate MS CONTIN morphine sulfate MSIR

ORAMORPH SR ROXANOL

oxycodone hcl PERCOLONE ROXICODONE ROXICODONE INTENSOL

QL oxycodone hcl/acetaminophen (325mg)

PERCOCET

QL oxycodone hcl/acetaminophen (325mg/5ml)

ROXICET

oxycodone hcl/aspirin PERCODAN tramadol hcl ULTRAM tramadol hcl/acetaminophen ULTRACET QL buprenorphine BUTRANS QL hydrocodone bit/acetaminophen

(250mg) STAGESIC-10

QL hydrocodone bit/acetaminophen (300mg)

XODOL 10-300

QL hydrocodone bit/acetaminophen (325mg/15ml) oral solution

HYCET

QL hydrocodone bitartrate HYSINGLA ER hydromorphone hcl DILAUDID-5 QL oxycodone hcl ER OXYCONTIN QL tapentadol hcl NUCYNTA QL tapentadol hcl ER NUCYNTA ER Antimigraine Preparations QL

QL ergotamine tartrate/caffeine CAFERGOT

MIGERGOT isomethept/acetaminop/dichlphn MIDRIN QL naratriptan AMERGE QL

QL rizatriptan benzoate MAXALT

MAXALT MLT QL sumatriptan IMITREX NASAL SPRAY QL

QL sumatriptan succinate IMITREX TABLET

IMITREX INJECTION QL

QL zolmitriptan ZOMIG

ZOMIG ZMT Narcoctic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations codeine/butalbit/acetamin/caff FIORICET WITH

CODEINE Narcotic & Salicylate Analgesics, Barbiturate & Xanthine codeine/butalbital/asa/caffein FIORINAL WITH

CODEINE #3 Narcotic Analgesic & Non-Salicylate Analgesic Combinations acetaminophen with codeine TYLENOL-CODEINE

NO.3 acetaminophen with codeine TYLENOL-CODEINE

NO.4 acetaminophen and codeine CAPITAL AND CODEINE Narcotic Withdrawal Therapy Agents QL +

CU PA + CU QL + CU

buprenorphine hcl/naloxone hcl buprenorphine hcl buprenorphine hcl/naloxone hcl

SUBOXONE SUBUTEX ZUBSOLV

PARKINSON’S DISEASE Antiparkinsonism Drugs, Anticholinergic benztropine mesylate COGENTIN trihexyphenidyl hcl ARTANE Antiparkinsonism Drugs, Other amantadine hcl SYMMETREL bromocriptine mesylate PARLODEL carbidopa/levodopa PARCOPA

SINEMET 25-100 SINEMET CR

carbidopa/levodopa/entacapone STALEVO entacapone COMTAN pramipexole di-hcl MIRAPEX



QL

ropinirole hcl

REQUIP REQUIP XL

selegiline hcl ELDEPRYL QL rasagiline mesylate AZILECT QL rotigotine NEUPRO Decarboxylase Inhibitors carbidopa LODOSYN SEIZURE DISORDER Anticonvulsants carbamazepine CARBATROL

TEGRETOL TEGRETOL XR

clonazepam KLONOPIN QL diazepam

divalproex sodium DIASTAT DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE

ethosuximide ZARONTIN QL

QL QL

ezogabine gabapentin lacosamide lacosamide

POTIGA NEURONTIN VIMPAT ORAL SOLUTION VIMPAT TABLETS

lamotrigine LAMICTAL levetiracetam KEPPRA oxcarbazepine TRILEPTAL phenytoin DILANTIN-125DILANTIN

CHEW TAB phenytoin sodium extended DILANTIN

PHENYTEK primidone MYSOLINE

QL

topiramate topiramate topiramate

TOPAMAX TOPAMAX SPRINKLE TROKENDI XR

valproate sodium DEPAKENE SYRUP valproic acid DEPAKENE CAPSULES zonisamide ZONEGRAN pregabalin LYRICA SKELETAL MUSCLE DISORDER Agents To Treat Periodic Paralysis PA dichlorphenamide KEVEYIS Skeletal Muscle Relaxants baclofen LIORESAL carisoprodol SOMA carisoprodol/aspirin SOMA COMPOUND chlorzoxazone PARAFON FORTE DSC cyclobenzaprine hcl FLEXERIL dantrolene sodium DANTRIUM metaxalone SKELAXIN methocarbamol ROBAXIN

ROBAXIN-750 orphenadrine citrate NORFLEX orphenadrine/aspirin/caffeine NORGESIC FORTE tizanidine hcl ZANAFLEX UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE Pancreatic Enzymes amylase/lipase/protease PANCRELIPASE 5,000 amylase/lipase/protease CREON

ULTRASE ULTRASE MT ZENPEP

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE Anticholinergics/Antispasmodics dicyclomine hcl BENTYL Belladonna Alkaloids belladonna alkaloids/phenobarb DONNATAL hyoscyamine sulfate ANASPAZ

LEVBID LEVSIN-SL

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE Anti-Ulcer Preparations misoprostol CYTOTEC sucralfate CARAFATE Anti-Ulcer-H.pylori Agents lansoprazole/amox tr/clarith PREVPAC Anticholinergics, Quaternary Ammonium chlordiazepoxide/clidinium br LIBRAX Histamine H2-Receptor Inhibitors cimetidine hcl TAGAMET famotidine PEPCID nizatidine AXID ranitidine hcl ZANTAC Intestinal Motility Stimulants Proton-Pump Inhibitors QL esomeprazole magnesium NEXIUM

lansoprazole PREVACID RX omeprazole capsules (RX) PRILOSEC CAPSULES

(RX) omeprazole magnesium tablets

(OTC) PRILOSEC OTC TABLETS (OTC)

pantoprazole sodium PROTONIX URINARY TRACT - FUNCTIONAL DISORDERS Benign Prostatic Hypertrophy/Micturition Agents alfuzosin

dutasteride finasteride

UROXATRAL AVODART PROSCAR

tamsulosin hcl FLOMAX Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents dutasetride/tamsulosin hcl JALYN Kidney Stone Agents PA cysteamine bitartrate PROCYSBI Overactive Bladder Agents, Beta-3 Adrenergic Recep mirabegron MYRBETRIQ Urinary Tract Analgesic Agents pentosan polysulfate sodium ELMIRON Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) phenazopyridine hcl PYRIDIUM Urinary Tract Antispasmodic, M(3) Selective Antagonists. solifenacin succindate VESICARE Urinary Tract Antispasmodic/Antiincontinence Agent oxybutynin chloride DITROPAN XL tolterodine tartrate DETROL

DETROL LA fesoterodine fumarate TOVIAZ VAGINAL DISORDERS Vaginal Antibiotics metronidazole METROGEL-VAGINAL

VANDAZOLE Vaginal Antifungals miconazole nitrate MONISTAT 3 butoconazole nitrate GYNAZOLE-1 Vaginal Estrogen Preparations estradiol cream

estradiol tablet ESTRACE VAGIFEM

estrogens, conjugated PREMARIN Vaginal Sulfonamides sulfanilamide AVC VITAMIN AND/OR MINERAL DEFICIENCY Fluoride Preparations sodium fluoride FLUORITAB

FLURA-DROPS FLURA-TABS LURIDE

Folic Acid Preparations folic acid FOLIC ACID Multivitamin Preparations



folic acid/mu-vits-min th VICON FORTE Pediatric Vitamin Preparations fluoride ion/iron/vit a,c&d TRI-VI-FLOR W/IRON fluoride ion/multivitamins POLY-VI-FLOR fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON fluoride ion/vit a,c&d FLUORABON BASIC Prenatal Vitamin Preparations prenatal vit 15/iron cb/fa/dss TRIADVANCE prenatal vit 16/iron cb/fa/dss VINATE GT prenatal vit 18/iron cb/fa/dss VINATE ULTRA prenatal vit 95/fe fum/fa PRENAVITE Vitamin B Preparations cyanocobalamin/fa/pyridoxine FOLGARD RX Vitamin D Preparations calcitriol

calcitriol ROCALTROL VECTICAL

ergocalciferol DRISDOL



SPECIALTY INJECTABLE CROSS REFERENCE LISTING

The following cross reference is being provided as a guide to formulary choices within prominent “specialty” injectable drug categories. General specialty categories are cross referenced to their corresponding formulary classification status and page number. This cross reference is not meant to be all-inclusive. Please refer to the Table of Contents or Index to determine formulary status of injectable medications not listed in this cross reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.). EPO Hematinics, Other Page 7 HEPATITIS C Hepatitis C Treatment Agents Page 9 HUMAN GROWTH FACTORS Growth Hormones Page 6 LOW MOLECULAR WEIGHT HEPARINS Heparin and Related Preparations Page 7 MULTIPLE SCLEROSIS Agents to Treat Multiple Sclerosis Page 10 RHEUMATOID ARTHRITIS Anti-Inflammatory Pyrimidine Synthesis Inhibitors Page 9

MEDICATION PRESCRIBING LIMITATIONS

1. AGE RESTRICTIONS (FORMULARY) Covered for ages: Differin

Epiduo Epiduo Forte

≤ 25 years old ≤ 25 years old ≤ 25 years old

Fabior ≥ 12 years old Ritalin LA 60mg ≤ 18 years old Ritalin SR ≤ 18 years old

2. AGE RESTRICTIONS (NON FORMULARY) Covered for ages: All carbinoxamine

containing products (i.e., Palgic, Tussafed, etc.)

≥ 2 years old

Atralin ≤ 25 years old Avita ≤ 25 years old Oracea ≥ 18 years old Refissa ≤ 25 years old Renova ≤ 25 years old Retin-A ≤ 25 years old Retin-A Micro ≤ 25 years old Retin-A Micro Pump ≤ 25 years old Solodyn ≥ 12 years old Tretin-X ≤ 25 years old

3. QUANTITY RESTRICTIONS (FORMULARY) Abilify

tablets solution

30 tablets per 30 days 900mL per 30 days

Abilify Discmelt 10mg 15mg

90 tablets per 30 days 60 tablets per 30 days

Adderall 60 tablets per 30 days Adderall XR

5mg, 10mg, 15mg 20mg, 25mg, 30mg

30 capsules per 30 days 60 capsules per 30 days

Advair Diskus 60 units per 30 days Advair HFA

Afinitor 12g (1 inhaler) per 30 days 30 per 30 days

Akynzeo 1 capsule per 28 days Aldara 24 packets per 30 days Alecensa 240 capsules per 30 days Alendronate solution 300mL per 28 days Ambien/Ambien CR 30 tablets per 30 days Amerge 18 tablets per 30 days

Androxy 120 tablets per 30 days Anoro Ellipta 60 blister packs per 30 days Aptivus

capsule solution

120 capsules per 30 days 380mL (4 bottles) per 30 days

Arixtra 2.5mg/0.5mL 5mg/0.4mL 7.5mg/0.6mL 10mg/0.8mL

5mL (10 syringes) per 30 days 4mL (10 syringes) per 30 days 6mL (10 syringes) per 30 days 8mL (10 syringes) per 30 days

Asmanex 1 inhaler per 30 days Asmanex HFA 13g (1 inhaler) per 30 days Astelin 60mL (2 bottles) per 30 days Astepro 60mL (2 bottles) per 30 days Atripla 30 tablets per 30 days Atrovent HFA 25.8g (2 inhalers) per 28 days Avinza

30mg, 45mg, 60mg, 75mg, 90mg

120mg


Azilect Baraclude

0.5mg, 1mg 0.05mg/5mL oral Solution

30 tablets per 30 days 30 tablets per 30 days 630mL (3 bottles) per 30 days

Belsomra Breo Ellipta

30 tablets per 30 days 60 units per 30 days

Brilinta 60 tablets per 30 days Butrans 4 patches per 28 days Caduet 30 tablets per 30 days Cafergot 40 tablets per 28 days Climara 4 patches per 28 days Clozaril 90 tablets per 30 days Colcrys 120 tablets per 30 days Combipatch 8 patches per 28 days Combivir

Complera 60 tablets per 30 days 30 tablets per 30 days

Concerta 18mg, 27mg, 54mg 36mg


Corlanor 60 tablets per 30 days Cotellic

Crestor 63 tablets per 28 days 30 tablets per 30 days

Cymbalta 60 capsules per 30 days Daliresp 30 tablets per 30 days Depo-Testosterone 10mL per 30 days Descovy 30 tablets per 30 days Desvenlafaxine ER

(Ranbaxy Brand) 30 tablets per 30 days

Dexedrine Spansule 5mg, 10mg 15mg


Diastat 1 kit per copay Dificid 20 tablets per 30 days Dulera 13g (1 inhaler) per 30 days Duragesic 10 patches per 30 days Edurant 30 tablets per 30 days Effient 30 tablets per 30 days Eliquis 60 tablets per 30 days Emend

40mg capsule 80mg capsule 125mg capsule

1 capsules per 28 days 2 capsules per 21 days 1 capsule per -21 days

Emend Trifold Pack 1 packet (3 capsules) per -21 days Emtriva

10mg/mL oral solution 200mg capsules

850mL (5 bottles) per 30 days 30 capsules per 30 days

Epivir 150mg tablets 300mg tablets 10mg/mL oral solution


Epivir HBV 100mg

oral solution

30 tablets per 30 days 720ml (3 bottles) per 30 days



Epzicom 30 tablets per 30 days Entresto 60 tablets per 30 days Evista

Evotaz Exelon patch Fetzima Flonase Focalin Focalin XR

30 tablets per 30 days 30 tablets per 30 days 30 patches per 30 days 30 capsules per 30 days 16g (1 bottle) per 30 days 60 tablets per 30 days 30 capsules per 30 days

Forteo 2.4mL (1 pen) per 28 days with a max duration of 2 years per lifetime

Fragmin 2500 units/0.2mL 5000 units/0.2mL 7500 units/0.3mL 10,000 units/1mL 12,500 units/0.5mL 15,000 units/0.6mL 18,000 units/0.72mL 25,000 units/ml

2mL (10 syringes) per 30 days 2mL (10 syringes) per 30 days 3mL (10 syringes) per 30 days 10mL (10 syringes) per 30 days 5mL (10 syringes) per 30 days 6mL (10 syringes) per 30 days 7.2mL (10 syringes) per 30 days 7.6ml (2 vials) per 30 days

Fuzeon 60 vials per 30 days Genvoya 30 tablets per 30 days Geodon 60 capsules per 30 days Glyxambi

Hepsera 30 tablets per 30 days 30 tablets per 30 days

Humulin N vial Kwikpen

40mL (4 vials) per 28 days 30mL (10 pens) per 28 days

Humulin R 100u/mL 500u/mL

40mL (4 vials) per 28 days 40mL (2 vials) per 28 days

Humulin R U-500 Kwikpen

8 pens (4 boxes of 2 pens) per 28 days

Humulin 70/30 vial Kwikpen


Humalog vial pen/cartridge

40mL (4 vials) per 28 days 30mL (10 pens/cartridges) per 28 days

Humalog Mix 50/50 / 75/25 vial Kwikpen


Hydrocodone bit/acetaminophen (maximum of 4gm of acetaminophen per day):

250mg 300mg 325mg 300mg/15ml soln 325mg/15ml elixir

16 tablets per 1 day supply 13 tablets per 1 day supply 12 tablets per 1 day supply 200mL per 1 day supply 184mL per 1 day supply

Hysingla ER 30 tablets per 30 days Imitrex

tablet nasal spray injection

18 tablets per 30 days 12 units per 30 days 4 units per 28 days

Inlyta 1mg 5mg


Intelence 25mg, 100mg 200mg


Invirase 200mg 500mg

300 capsules per 30 days 120 tablets per 30 days

Invokamet 60 tablets per 30 days Invokamet XR 60 tablets per 30 days Invokana 30 tablets per 30 days Isentress

400 mg tablets 25mg, 100mg tablets 100mg powder

60 tablets per 30 days 180 chewable tablets per 30 days 60 packets per 30 days

Janumet 60 tablets per 30 days Janumet XR

100-1000mg 30 tablets per 30 days

50-1000mg 50-500mg


Januvia 30 tablets per 30 days Jentadueto 60 tablets per 30 days Jardiance 30 tablets per 30 days Juxtapid

5mg, 10mg, 30mg, 40mg, 60mg 20mg


Kaletra 100-25mg tablets 200-50mg tablets oral solution


Lantus vial Solostar


Latuda 20mg, 40mg, 60mg, 120mg 80mg Lexiva

suspension tablet

30 tablets per 30 days 60 tablets per 30 days 1800mL (8 bottles) per 30 days 120 tablets per 30 days

Linzess 30 capsules per 30 days Livalo 30 tablets per 30 days Lovaza 120 capsules per 30 days Lovenox

30mg/0.3mL 40mg/0.4mL 60mg/0.6mL 80mg/0.8mL 100mg/1mL 120mg/0.8mL 150mg/1mL 300mg/3mL

6mL (20 syringes) per 30 days 8mL (20 syringes) per 30 days 12mL (20 syringes) per 30 days 16mL (20 syringes) per 30 days 20mL (20 syringes) per 30 days 16mL (20 syringes) per 30 days 20mL (20 syringes) per 30 days 30mL (10 vials) per 30 days

Lumigan 2.5mL per 30 days Lunesta 30 tablets per 30 days Lynparza 16 capsules per day Marinol 60 capsules per 30 days Maxalt/Maxalt MLT 18 tablets per 30 days Metadate CD

10mg, 20mg, 40mg, 60mg 30mg


Metadate ER 90 tablets per 30 days Methadone HCl injection

solution 120mL (6 vials) per 30 days

Methylin chewable tablet 90 tablets per 30 days Migergot 20 units per 28 days Morgidox

50mg, 100mg 60 capsules per 30 days

Movantik

30 tablets per 30 days

MS Contin 90 tablets per 30 days Namenda

tablet titration pack solution

60 tablets per 30 days 49 tablets per 28 days 300mL per 30 days

Namenda XR capsules titration pack


Namzaric capsules

titration pack


Narcan 2 boxes (4 nasal sprays) per 30 days

Nasacort AQ 16.5g (1 canister) per 30 days Nasarel 25mL (1 bottle) per 30 days Nasonex 17g (1 canister) per 30 days Neupro 30 patches per 30 days Nexium

capsules packets

30 capsules per 30 days 30 packets per 30 days

Nilandron 60 tablets for the first 30 days, then 30 tablets per 30 days



Norvir oral solution capsules/tablets

480mL (2 bottles) per 30 days 360 capsules/tablets per 30 days

Nucynta 180 tablets per 30 days Nucynta ER 60 tablets per 30 days Nuvaring 1 ring per 28 days Odefsey 30 tablets per 30 days Ortho Evra 3 patches per 28 days Otrexup 1.6mL per 28 days Oxycodone hcl/acetaminophen (maximum of 4g acetaminophen

per day): 325mg

500mg 650mg 325mg/5mL soln

12 tablets per 1 day supply 8 tablets/capsules per 1 day supply 6 tablets per 1 day supply 61mL per 1 day supply

Oxycontin 10mg, 15mg, 20mg, 30mg, 40mg, 60mg 80mg


Perforomist 120mL per 30 days Picato

0.015% 0.05%

3 tubes per 56 days 2 tubes per 56 days

Plavix 300mg tablet 4 tablets per 30 days Potiga

50mg 200mg, 300mg, 400mg


Prezcobix 30 tablets per 30 days Prezista

suspension 75mg 150mg 400mg, 600mg 800mg

400mL per 30 days 480 tablets per 30 days 240 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days

Pristiq 30 tablets per 30 days Promacta

Provigil 30 tablets per 30 days 60 tablets per 30 days

Pulmicort Flexhaler 1 inhaler per 30 days Pulmicort Respules 60mL (30 respules) per 30 days Qnasl 8.7g (1 canister) per 30 days Qnasl Children

Quillichew ER 20mg, 40mg 30mg

4.9g (1 canister) per 30 days 30 tablets 30 per days 60 tablets per 30 days

Quillivant XR 60mL 120mL 150mL 180mL

60mL (1 bottle) per 30 days 240mL (2 bottles) per 30 days 300mL (2 bottles) per 30 days 360mL (2 bottles) per 30 days

QVAR 17.4g (2 inhalers) per 30 days Ranexa

500mg 1000mg

Rayaldee

120 tablets per 30 days 60 tablets per 30 days 60 capsules per 30 days

Razadyne solution tablets

200mL (2 bottles) per 30 days 60 tablets per 30 days

Razadyne ER 30 capsules per 30 days Requip XL 30 tablets per 30 days Restasis SDV

Restasis MDV 60 single use vials per 30 days 1 multidose vial per 30 days

Retrovir syrup capsules tablets

1920mL (8 bottles) per 30 days 180 capsules per 30 days 60 tablets per 30 days

Revlimid Rexulti


Reyataz 150mg, 200mg 300mg 50mg

60 capsules per 30 days 30 capsules per 30 days 150 packets per 30 days

Risperdal/Risperdal M-tab 60 tablets per 30 days Risperdal solution 240mL per 30 days Ritalin 90 tablets per 30 days Ritalin LA

10mg, 20mg, 40mg, 60mg 30mg


Ritalin SR 90 tablets per 30 days Saphris

Seasonale 60 tablets per 30 days 91 tablets per 84 days Extra copay for every 31 days

Selzentry 75mg, 150mg

25mg, 300mg


Serevent Diskus 60 doses (1 Diskus) per 30 days Seroquel 90 tablets per 30 days Silenor

Sonata 30 tablets per 30 days 30 capsules per 30 days

Spiriva 30 inh capsules per 30 days Spiriva Respimat 1 inhaler per 30 days Stiolto Respimat 4g (60 inhalations) per 30 days Strattera

10mg, 18mg, 25mg, 40mg 60mg, 80mg, 100mg


Stribild 30 tablets per 30 days Striverdi Respimat

Suboxone 2/0.5mg, 4/1mg 8/2mg, 12/3mg Tablets

4g (60 inhalations) per 30 days 30 films per 30 days 60 films per 30 days 90 tablets per 30 days

Subutex Symbicort Symbyax

90 tablets per 30 days 1 inhaler per 30 days (10.2 grams) 30 capsules per 30 days

Synjardy Synjardy XR

5/1000mg,12.5/1000mg 10/1000mg, 25/1000mg

60 tablets per 30 days 2 tablets per day 1 tablet per day

Tagrisso 1 tablet per day Tamiflu

suspension 30mg 45mg, 75mg

360mL per 183 days 40 tablets per 183 days 20 tablets per 183 days

Tarceva 30 tablets per 30 days Tivicay 30 tablets per 30 days Toradol

Trintellix Viibryd Vimpat

50mg, 100mg, 150mg, 200mg 10mg/ml oral solution

Vraylar All Strengths Titration Pack

Vyvanse Zubsolv

0.7mg/0.18mg 1.4/0.36mg 2.9/0.71mg 5.7/1.4mg 11.4/2.9mg 8.6/2.1mg

20 tablets per fill 30 tablets per 30 days 30 tablets per 30 days 60 tablets per 30 days 1200mL per 30 days 30 capsules per 30 days 7 blisters (1 dose-pack) per 28 days 30 capsules/tablets per 30 days 30 sublingual tablets per 30 days 60 sublingual tablets per 30 days

NOTE: The FDA recommends a maximum of 5 days of therapy with this drug Toujeo 13.5mL (9 pens) per 28 days Tradjenta 30 tablets per 30 days Travatan 2.5mL per 30 days Travatan Z 2.5mL per 30 days Triumeq 30 tablets per 30 days Trizivir

Trokendi XR 25mg, 50mg, 100mg 200mg

60 tablets per 30 days 30 capsules per 30 days 60 capsules per 30 days

Trulicity 2mL (4 pens) per 28 days



Truvada 30 tablets per 30 days Tybost 30 tablets per 30 days Uloric 30 tablets per 30 days Vancocin 40 capsules per 30 days Vascepa

0.5g 1g


Viagra 6 tablets per 30 days Vibramycin 100mg 60 capsules per 30 days Vibra-Tabs 60 tablets per 30 days Victoza 9mL (3 pens) per 30 days Videx Solution 600mL (six 2g bottles or three 4g

bottles) per 30 days

Videx EC 125 mg, 200 mg 250 mg, 400 mg


Viramune solution tablets


Viramune XR 100mg 400mg


Viread powder tablets

240g powder per 30 days 30 tablets per 30 days

Vistogard granules

24 packets per 14 days

Vivelle-Dot 8 patches per 28 days

Xalkori 60 capsules per 30 days

Xarelto 10mg, 20mg 15mg


Xiidra 60 vials per 30 days Zenzedi

2.5mg, 5mg, 7.5mg, 15mg 10mg 20mg, 30mg

90 tablets per 30 days 180 tablets per 30 days 60 tablets per 30 days

Zerit oral solution capsules


Zetia 30 tablets per 30 days Ziagen

solution tablets


Zofran solution 50mL per 15 days Zomig/Zomig ZMT

tablet nasal spray

12 tablets per 30 days 12 units per 30 days

Zurampic Zyprexa


Zyprexa Zydis 30 tablets per 30 days

4. QUANTITY RESTRICTIONS (NON FORMULARY) Aciphex

sprinkle delayed-release tablets


Acticlate 75mg, 150mg 60 tablets per 30 days Actonel

5mg, 30mg 35mg 150mg

30 tablets per 30 days 4 tablets per 28 days 1 tablet per 28 days

Aerospan 17.8g (2 inhalers) per 30 days Afrezza

4 unit 30-4 unit + 60-8 unit 60-4 unit + 30-8 unit 60-8 unit + 30-12 unit Titration pack

180 cartridges (2 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days 360 cartridges (4 kits) per 28 days 180 cartridges (1 kit) per 28 days

Allegra suspension 300mL per 30 days Alsuma

Amitiza 4 units per 28 days 60 capsules per 30 days

Anoro Ellipta 60 blister packs per 30 days Anzemet

50mg 100mg

8 tablets per fill 4 tablets per fill

Aplenzin 30 tablets per 30 days Aptiom

200, 400 600mg, 800mg


Arcapta 30 capsules per 30 days Arnuity Ellipta 30 blister packs per 30 days Atelvia

Auryxia 4 tablets per 28 days 12 tablets per day

Avidoxy 60 tablets per 30 days

Axert 12 tablets per 30 days

Banzel 200mg 400mg solution

480 tablets per 30days 240 tablets per 30 days 2400mL per 30 days

Benoxyldoxy 1 kit per 30 days Brisdelle 30 capsules per 30 days Briviact

tablet oral solution

Brovana Bunavail

2.1/0.3mg 4.2/0.7mg, 6.3/1mg

60 tablets per 30 days 600ml per 30 days 120mL per 30 days 30 films per 30 days 60 films per 30 days

Bupap 180 tablets per 30 days Cambia 9 packets per 30 days Caverject 1 dose per 5 days Cesamet 180 capsules per 30 days Chantix 56 tablets per 28 days Cialis

2.5mg, 5mg 10mg, 20mg


Clarinex 2.5mg, 5mg reditab 5mg syrup


Clarinex D 12 hour 60 tablets per 30 days Clarinex D 24 hour 30 tablets per 30 days Climara Pro

Clozapine ODT 4 patches per 28 days 90 tablets per 30 days

Conzip 30 capsules per 30 days Cosopt PF 60 droperettes per 30 days Daytrana 30 patches per 30 days Demerol

solution tablets

900mL per 30 days 180 tablets per 30 days

Depo-Provera 1mL per 84 days Depo-subQ Provera 104 0.65mL per 84 days Desoxyn 150 tablets per 30 days Desvenlafaxine ER

(Fumarate) 30 tablets per 30 days

Dexilant D.H.E. 45

30 capsules per 30 days 30 ampules per 28 days

Diclegis 120 tablets per 30 days Doryx

50mg 200mg


Doryx MPC 120mg Dutoprol

25-12.5mg, 50-12.5mg 100-12.5mg

Dyanavel XR

60 tablets per 30 days 30 tablets per 30 days 60 tablets per 30 days 240mL per 30 days

Dymista 23g (1 bottle) per 30 days Edex 1 dose per 5 days Embeda

20-0.8mg, 30-1.2mg, 50-2mg, 60-2.4mg, 80-3.2mg

100-4mg

2 capsules per day 4 capsules per day

Emsam 30 patches per 30 days Epaned 1200mL per 30 days



Ergomar SL 40 tablets per 28 days Esomeprazole Strontium

24.65mg 49.3mg


Estring 1 ring per 90 days Fanapt 60 tablets per 30 days Fanapt Titration Pack 8 tablets (1 pack) per 28 days Fazaclo 90 tablets per 30 days Felbatol

400mg 600mg 600mg/5ml solution


Firmagon 80mg/vial 1 vial per 30 days Firmagon 120mg/vial 2 vials per 365 days Foradil 60 capsules per 30 days Frova 18 tablets per 30 days Fulyzaq 60 tablets per 30 days

Fycompa

2mg 4mg, 6mg 8mg, 10mg, 12mg 0.5mg/mL suspension

120 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days 680mL (2 bottles) per 28 daysy

Gabitril 2mg, 4mg, 12mg 16mg


Granisol solution 60mL per 30 days Hemangeol 360mL (3 bottles) per 30 days Hydrocodone bit/

acetaminophen (max 4gm per day)

Incruse Ellipta 30 blisters per 30 days Intuniv 30 tablets per 30 days Invega 1.5mg, 3mg, 9mg 30 tablets per 30 days Invega 6mg 60 tablets per 30 days Iprivask 6 syringes per 30 days Kapvay 120 tablets per 30 days Karbinal ER 960mL (2 bottles) per 30 days Kytril 8 tablets per 30 days Lamictal ODT

25mg, 50mg 100mg 200mg


Lamictal XR 25mg, 50mg 100mg 200mg, 250mg, 300mg


Lescol 60 tablets per 30 days Liptruzet 30 tablets per 30 days LoSeasonique 91 tablets per 84 days Luvox CR 60 capsules per 30 days Luzu 60g (1 tube) per 28 days Magnacet 400mg

Menostar 10 tablets per 1 day supply 4 patches per 30 days

Migranal 8 vials per 28 days Mirapex ER 30 tablets per 30 days Mitigare

Mondoxyne NL 50mg, 75mg, 100mg


Monodox 50mg, 75mg, 100mg

60 capsules per 30 days

Muse 1 dose per 5 days Myalept 11.3mg vial 30 vials per 30 days Nicotrol cartridge 1008 cartridges (6 inhalers) per 90

days Nicotrol NS

Nuvigil 50mg 150mg, 200mg, 250mg

160mL (4 Packs) per 90 days 90 tablets per 30 days 30 tablets per 30 days

Obredon 600mL per 10 days Oleptro ER

150mg 300mg


Onfi Tablets

60 tablets per 30 days 480mL per 30 days

Suspension Opana ER

5mg, 7.5mg, 10mg, 15mg, 20mg 30mg, 40mg


Oracea 30 capsules per 30 days Osphena 30 tablets per 30 days Oxtellar XR

150mg, 300mg 600mg


Oxycodone HCl/acetaminophen (maximum of 4g acetaminophen per day)

Patanase Pataday

30.5g (1 bottle) per 30 days 2.5ml (1 bottle) per 30 days

Pradaxa 60 capsules per 30 days Procentra

Qbrelis 1800mL per 30 days 1200ml (8 bottles) per 30 days

Qudexy XR 25mg, 50mg, 100mg 150mg, 200mg


Rasuvo 7.5mg/0.15mL 10mg/0.2mL 12.5mg/0.25mL 15mg/0.3mL 17.5mg/0.35mL 22.5mg/0.46mL 25mg/0.5mL 27.5mg/0.55mL

30mg/0.6mL

1.6mL (4 syringes) per 28 days 0.8mL (4 syringes) per 28 days 1mL (4 syringes) per 28 days 1.2mL (4 syringes) per 28 days 1.4mL (4 syringes) per 28 days 1.8mL (4 syringes) per 28 days 2mL (4 syringes) per 28 days 2.2mL (4 syringes) per 28 days 2.4mL (4 syringes) per 28 days

Relenza 40 disk inhalers per 183 days Relpax 12 tablets per 30 days Rescula 10mL (2 bottles) per 30 days Rhinocort Aqua

Rubraca 17.2g (2 canisters) per 30 days 120 tablets per 30 days

Rytary 300 capsules per 30 days Ryzodeg 70/30 30ml (10 pens) per 28 days Sabril 180 tablets per 30 days Samsca

15mg tablets 30mg tablets


Sancuso 4 patches per 28 days Savaysa 30 tablets per 30 days Seasonique 91 tablets per 84 days Seroquel XR 30 tablets per 30 days Sitavig 4 tablets per 365 days Solaraze 100g per fill Solodyn 30 tablets per 30 days Sotylize

250mL 480mL

2000mL (8 bottles) per 30 days 3840mL (8 bottles) per 30 days

Spritam 250mg, 500mg,750mg 1000mg


Sprix 5 bottles per 30 days Sumavel DosePro 4 units per 28 days Targadox

Tasmar 120 tablets per 30 days 90 tablets per 30 days

Timoptic Ocudose 60 droperettes per 30 days Trezix 10 capsules per day Trulance

Tuzistra XR 30 tablets per 30 days 600mL per 30 days

Varubi Veltassa Vemlidy

2 tablets per 14 days 1 packet per day 30 tablets per 30 days

Versacloz 540mL per 30 day Vytorin 30 tablets per 30 days Xartemis XR 360 tablets per 30 days Xerese 10gm (2 tubes) per 365 days Xifaxan 200mg

Xodol 5-300mg 9 tablets per fill 13 tablets per 1 day supply

Xolox 500mg Xyzal solution

8 tablets per 1 day supply 300mL per 30 days



Zamicet Soln 325mg/15ml Zegerid

Packets Capsules

184mL per 1 day supply 30 packets per 30 days 30 capsules per 30 days

Zelapar 60 tablets per 30 days Zohydro ER 60 capsules per 30 days Zontivity 30 tablets per 30 days Zyclara

2.5% 3.75% pump

3.75% packet

7.5 grams (1 bottle) per 28 days 7.5 grams (1 bottle) per 28 days 28 packets per 28 days

Zyclara 2.5% 3.75% pump 3.75% packet

7.5 grams (1 bottle) per 28 days 7.5 grams (1 bottle) per 28 days 28 packets per 28 days

5. STEP THERAPY EDITS (FORMULARY) Daliresp Trial of Spiriva, Serevent,Breo Ellipta, Advair, or Dulera within the past 120 days

Gianvi Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Loryna Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Methadone HCl injection solution

Trial of lower strength oral methadone tablets or solution within the past 120 days.

Niaspan Trial of generic/multisource statin (atorvastatin, lovastatin, pravastatin, or simvastatin), or generic/multisource gemfibrozil or fenofibrate within the past 365 days

Ocella Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Syeda Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Vestura Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Yasmin 28 Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Yaz Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Zarah Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Zenzedi (2.5mg, 7.5mg) Trial of a multisource dextroamphetamine sulfate tablet or dextroamphetamine solution within the past 120 days

Zocor (80mg only) Trial of simvastatin 80mg or Vytorin 10/80mg within the past 365 days

Zocor (80mg only) Trial of simvastatin 80mg or Vytorin 10/80mg within the past 365 days

6. STEP THERAPY EDITS (NON FORMULARY)

Aerospan Trial of at least two of the following: QVAR, Asmanex or Pulmicort within the past 365 days

Amitiza

Anoro Ellipta

Trial of Linzess or Movantik within the past 120 days. Trial of Stiolto Respimat and one of the following: Spiriva, Striverdi or Serevent within the past 365 days

Arcapta Trial of Serevent Diskus or Striverdi Respimat within the past 120 days

Arnuity Ellipta Trial of at least two of the following: QVAR, Asmanex or Pulmicort within the past 365 days

Avandia/ Avandaryl/

Avandamet

Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above within the past 120 days.

Beyaz Bravelle

Trial of 2 generic/multisource oral contraceptives within the past 365 days Trial of Gonal-F or Gonal-F-RFF required within the past 120 days

Follistim AQ

Trial of Gonal-F or Gonal-F-RFF required within the past 120 days

Foradil Trial of Serevent Diskus or Striverdi Respimat within the past 120 days

Giazo Trial of balsalazide or Apriso within the past 120 days

Incruse Ellipta Trial of preferred LAMA (Spiriva) within the past 120 days

Neo-Synalar Trial of fluocinolone and bacitracin within the past 365 days

Novantrone Trial of an antineoplastic agent within the past 120 days. If step not met, follow prior authorization guideline.

Pradaxa Trial of Eliquis and Xarelto within the past 365 days

Rasuvo Trial of Otrexup and methotrexate tablet or solution for injection within the past 365 days.

Ryzodeg 70/30 Trial of preferred long acting insulin and preferred pre-mixed insulin) within the past 365 days

Safyral Trial of two different non-drospirenone oral contraceptives (containing levonorgestrel, norethindrone, norgestimate, norgestrel, desogestrel, or ethinynodiol ace.) within the past 365 days.

Savaysa Trial Eliquis and Xarelto within the past 365 days

Sitavig Trial of oral acyclovir, valacyclovir or famciclovir within the past 120 days



Trulance

Uceris tablet

Trial of Linzess within the past 120 days. Trial of balsalazide within the past 120 days

Vytorin (10/80mg only) Trial of simvastatin 80mg or Vytorin 10/80mg within the past 365 days

Xerese Trial of oral acyclovir, valacyclovir or famciclovir within the past 120 days

Xerese Trial of oral acyclovir, valacyclovir or famciclovir within the past 120 days

7. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY) Actiq Adcirca Adempas Afinitor /Afinitor Disperz Aldara Alecensa Androgel

Aubagio Avonex Avonex Admin Pack Axiron Bosulif

Cabometyx Depen Emverm Enbrel Epclusa

Farydak Firazyr Gattex Gilenya Gilotrif Gleevec

Grastek Harvoni Humira

Ibrance Iclusig Imbruvica

Impavido Inlyta

Intron A Iressa Jakafi

Juxtapid Kalydeco Keveyis Kisqali

Korlym Kynamro Lenvima Letairis Leukine

Lonsurf Lynparza Mekinist Neulasta Neupogen Nexavar

Ninlaro Norditropin Odomzo Ofev Omnitrope Opsumit

Oralair Orfadin Orkambi

Otezla Pegasys

Pegasys Proclick Plegridy Plegridy Pen Pomalyst

Praluent Procrit Procysbi Promacta Pulmozyme

Ragwitek Rebif Rebif Rebidose Repatha

Revatio tablets Revlimid Sprycel

Stelara SC Stivarga

Strensiq Subutex Sutent Tafinlar Tagrisso Tarceva Targretin Tasigna Tecfidera Temodar capsules Thalomid Tobi Tobi PodhalerTobi TracleerTobi Podhaler Tracleer Tykerb

Uptravi Valchlor

Venclexta Votrient Xalkori

Xeljanz Xeljanz XR

Xeloda Xenazine

Xermelo Xifaxan 550mg Xtandi

Xuriden Zelboraf Zydelig Zykadia Zytiga Zyvox

8. PRIOR AUTHORIZATION RESTRICTIONS (NON-FORMULARY) Abraxane*

Actemra SC Actemra IV* Adcetris* Addyi Afrezza Alimta* Ampyra Amturnide Anadrol-50



Androderm Apokyn Aranesp Arzerra* Austedo Avastin* Bavencio* Beleodaq* Belviq Belviq XR Berinert Bethkis Bivigam* Blincyto* Botox* Caprelsa Carimune NF Nanofiltered* Cerezyme* Cholbam Cialis Cinryze Cinqair Contrave Cuprimine Cuvitru Cyramza* Darzalex* Duopa Dysport* Egrifta Elelyso* Elspar* Emflaza Empliciti* Entyvio* Epogen Erbitux* Erwinaze* Euflexxa* Evekeo Exalgo Exondys 51* Eylea* Faslodex* Flebogamma DIF* Flolan* Gamastan S-D* Gammagard Liquid Gammagard S-D* Gammaked Gammaplex* Gamunex-C Gazyva* Gel-One* Gleostine Granix* Halaven* Herceptin* Hetlioz Hizentra H.P. Acthar* Hyalgan* Hymovis* Hyqvia IG component Ilaris* Imlygic* Incivek Increlex Inflectra* Ingrezza Iprivask Istodax* Ixempra*

Jublia Kadcyla* Kalbitor* Kanuma* Keytruda* Kineret Kitabis Pak Kyprolis* Lartruvo* Lemtrada* Lucentis* Lumizyme* Macugen* Makena Marqibo* Mircera Monovisc* Mozobil* Myobloc* Natpara Neulasta Delivery kit* Northera Novantrone* Nucala* Nuedexta Nuplazid Nymalize Ocaliva Octagam* Ocrevus* Olysio Oncaspar* Onivyde* Opdivo* Orencia IV* Orencia SC Orenitram ER Orthovisc* Oxandrin Pegintron Pegintron Redipen Perjeta* Photofrin* Portrazza* Privigen* Prolia* Qutenza Ravicti Relistor Remicade* Remodulin Revatio Vial* Revatio suspension Rituxan* Rubraca Saxenda Serostim Signifor Siliq Simponi SC Simponi Aria IV* Sirturo Solaraze Soliris* Spinraza* Stelara IV* Striant Sucraid Supartz* Suprenza ODT Sylvant* Synagis* Synribo*



Synvisc* Synvisc-One* Tecentriq* Technivie Tekamlo Tekturna Tekturna HCT Temodar vial* Testred Tev-Tropin Translarna Thyrogen* Torisel* Tymlos Tysabri* Tyvaso Unituxin* Valturna Vecamyl Vectibix* Velcade* Veletri* Veltassa Ventavis Viberzi Vimizim Vogelxo Vpriv* Xeomin* Xgeva* Xolair* Xyrem Yervoy*

Yondelis* Zaltrap* Zarxio Zavesca Zepatier Zinbryta Zoladex* Zorbtive Zyclara

*=Dependent on plan benefit. If covered under pharmacy benefit then nonformulary with prior authorization.

9. CONCURRENT USE EDITS (FORMULARY) Suboxone Subutex

Zubsolv

10. CONCURRENT USE EDITS (NON-FORMULARY) Bunavail

MedPerform Low Formulary INDEX


5-grass pollen extract.......................................... 1 8-MOP ................................................................ 5 abacavir sulfate ................................................. 9 abacavir sulfate/lamivudine ................................. 9 abacavir/dolutegravir/lamivudine ......................... 9 abacavir/lamivudine/zidovudine ...................... 9 ABBOTT DIABETIC SUPPLIES .......................... 6 ABILIFY DISCMELT ........................................... 2 ABILIFY SOLUTION ........................................... 2 ABILIFY TABLET ................................................ 2 abiraterone acetate ........................................... 11 acarbose ............................................................ 5 ACCUPRIL ......................................................... 3 ACCURETIC ....................................................... 2 acebutolol hcl .................................................... 3 acetaminophen with codeine ......................... 12 acetazolamide ................................................... 7 acetic acid ......................................................... 6 acetic acid/aluminum acetate .......................... 6 acetic acid/hydrocortisone ............................... 6 acetylcysteine ................................................. 12 acitretin ............................................................... 5 ACLOVATE ........................................................ 5 ACTIGALL ........................................................ 10 ACTIQ ............................................................... 12 ACTOPLUS MET ................................................ 6 ACTOPLUS MET XR .......................................... 6 ACTOS ............................................................... 6 ACULAR ............................................................. 7 ACULAR LS ........................................................ 7 acyclovir ........................................................ 5, 9 ADALAT CC ....................................................... 3 adalimumab ...................................................... 10 adapalene .......................................................... 4 ADCIRCA ........................................................... 3 ADDERALL ......................................................... 2 ADDERALL XR ................................................... 2 adefovir dipivoxil ............................................ 10 ADEMPAS .......................................................... 3 ADVAIR DISKUS ................................................ 1 ADVAIR HFA ...................................................... 1 afatinib .............................................................. 11 AFINITOR ......................................................... 11 AFINITOR DISPERZ ......................................... 11 AFTERA ............................................................. 4 AGRYLIN ............................................................ 8 AK-TRACIN ........................................................ 7 AKYNZEO .......................................................... 1 ALAMAST ........................................................... 7 ALA-TET ............................................................. 9 ALAWAY OTC .................................................... 7 albuterol sulfate ................................................ 1 ALBUTEROL SULFATE ..................................... 1 alclometasone dipropionate ............................ 5 ALDACTONE ...................................................... 3 ALDARA ............................................................. 8 ALDOMET .......................................................... 3 ALECENSA ...................................................... 11 alectinib hydrochloride ...................................... 11 alendronate sodium .......................................... 6 alendronate sodium solution ........................... 6 alendronate sodium/vitamin d3 ........................... 6 alfuzosin .......................................................... 13 alirocumab .......................................................... 3 ALKERAN ......................................................... 11 allopurinol ......................................................... 7 ALOCRIL ............................................................ 7 ALOMIDE ........................................................... 7 ALORA ............................................................... 8 ALPHAGAN P ..................................................... 7 alprazolam ......................................................... 2 ALPRAZOLAM INTENSOL ................................. 2 ALREX ................................................................ 7 ALTACE .............................................................. 3 altretamine ........................................................ 11 aluminum chloride ............................................ 5 ALUPENT ........................................................... 1 amantadine hcl ................................................ 12 AMARYL ............................................................. 5 AMBIEN .............................................................. 2 AMBIEN CR ........................................................ 2 ambrisentan ........................................................ 3 amcinonide ........................................................ 5 AMERGE .......................................................... 12 AMINOPHYLLIN ................................................. 1

aminophylline .................................................... 1 amiodarone hcl ................................................. 2 amitriptyline hcl ................................................ 1 amlodipine bes/olmesartan med ...................... 3 amlodipine besylate .......................................... 3 amlodipine besylate/benazepril ....................... 2 amlodipine/atorvast cal .................................... 4 amlodipine/valsartan ........................................... 3 amlodipine/valsartan/hctz ................................ 3 AMNESTEEM ..................................................... 4 amox tr/potassium clavulanate ........................ 8 amoxapine ......................................................... 2 amoxicillin trihydrate ........................................ 8 AMOXIL .............................................................. 8 amphet asp/amphet/d-amphet ......................... 2 ampicillin trihydrate .......................................... 8 amylase/lipase/protease ................................. 13 ANAFRANIL........................................................ 2 anagrelide hcl .................................................... 8 ANALPRAM HC ................................................ 10 ANAPROX ........................................................ 10 ANAPROX DS .................................................. 10 ANASPAZ ......................................................... 13 anastrozole ...................................................... 11 ANDROGEL........................................................ 8 ANDROID ........................................................... 8 ANDROXY .......................................................... 8 ANSAID ............................................................ 10 ANTABUSE ........................................................ 2 anthralin .............................................................. 5 Antipsychotics, Atypical, D3/D2 Partial

Agonist/5HT Mixed ....................................... 2 antipyrine/benzocaine otic .................................. 6 ANTIVERT .......................................................... 1 ANUSOL-HC ..................................................... 10 APEXICON ......................................................... 5 APEXICON E ...................................................... 5 apixaban ............................................................. 7 aprepitant .......................................................... 1 APRESOLINE ..................................................... 3 APRISO ............................................................ 10 APTIVUS ............................................................ 9 ARALEN PHOSPHATE ...................................... 9 ARAVA ............................................................. 10 ARICEPT ............................................................ 1 ARICEPT ODT .................................................... 1 ARIMIDEX ........................................................ 11 aripiprazole........................................................ 2 ARIXTRA ............................................................ 8 ARMOUR THYROID ........................................... 7 AROMASIN....................................................... 11 ARTANE ........................................................... 12 ASENDIN ............................................................ 2 asfotase alfa ..................................................... 12 ASMANEX .......................................................... 1 ASMANEX HFA .................................................. 1 ASTELIN ............................................................. 1 ASTEPRO .......................................................... 1 ATARAX ............................................................. 1 atazanavir sulfate ................................................ 9 atazanavir sulfate/cobicistat ................................ 9 atenolol .............................................................. 3 atenolol/chlorthalidone .................................... 3 ATIVAN ............................................................... 2 atomoxetine hcl ................................................... 2 atorvastatin calcium ......................................... 3 ATRIPLA ............................................................. 9 atropine sulfate ................................................. 7 ATROVENT .................................................. 1, 12 ATROVENT HFA ................................................ 1 AUBAGIO ......................................................... 11 AUGMENTIN ...................................................... 8 AUGMENTIN ES-600 ......................................... 8 AUGMENTIN XR ................................................ 8 AVALIDE ............................................................ 3 AVAPRO ............................................................. 3 AVC .................................................................. 13 AVELOX ............................................................. 9 AVELOX ABC PACK .......................................... 9 AVIANE-28 ......................................................... 4 AVINZA ............................................................. 12 AVLOSULFON .................................................... 9 AVONEX ........................................................... 11 AVONEX ADMINISTRATION PACK ................. 11 AXID ................................................................. 13

AXIRON .............................................................. 8 axitinib .............................................................. 11 AYGESTIN.......................................................... 8 azathioprine ....................................................... 8 azelastine hcl ................................................ 1, 7 AZILECT ........................................................... 13 azilsartan med/chlorthalidone ............................. 3 azilsartanl ........................................................... 3 azithromycin ...................................................... 8 AZOPT ................................................................ 7 AZOR .................................................................. 3 aztreonam lysine ................................................. 8 AZULFIDINE ..................................................... 10 bacitracin ........................................................... 7 bacitracin/polymyxin b sulfate ......................... 7 baclofen ........................................................... 13 BACTRIM DS ...................................................... 8 BACTROBAN ..................................................... 4 BACTROBAN NASAL ....................................... 12 balsalazide disodium ...................................... 10 BARACLUDE .................................................... 10 becaplermin ........................................................ 6 beclomethasone dipropionate ............................. 1 belladonna alkaloids/phenobarb ................... 13 BELSOMRA ........................................................ 2 benazepril hcl .................................................... 3 benazepril/hydrochlorothiazide ....................... 2 BENEMID ........................................................... 7 BENICAR ............................................................ 3 BENICAR HCT ................................................... 3 BENTYL ............................................................ 13 BENZAMYCIN .................................................... 4 BENZAMYCIN PAK ............................................ 4 BENZOTIC.......................................................... 6 benzoyl peroxide............................................... 4 benzoyl peroxide/hydrocortison .......................... 4 benztropine mesylate ..................................... 12 besifloxacin hcl drops susp 0.6% ........................ 7 BESIVANCE ....................................................... 7 BETAGAN .......................................................... 7 Betalactams ........................................................ 8 betamet diprop/prop gly ................................... 5 betamethasone dipropionate ........................... 5 betamethasone valerate ................................... 5 BETAPACE ......................................................... 3 BETAPACE AF ................................................... 3 betaxolol hcl ...................................................... 7 bethanechol chloride ...................................... 11 BETIMOL ............................................................ 7 BETOPTIC .......................................................... 7 BETOPTIC S ...................................................... 7 bexarotene .................................................... 5, 11 BIAXIN ................................................................ 8 BIAXIN XL .......................................................... 8 bicalutamide .................................................... 11 BIDIL ................................................................... 4 BILTRICIDE ........................................................ 9 bimatoprost ......................................................... 7 bisoprolol fumarate .......................................... 3 bisoprolol fumarate/hctz .................................. 3 BLEPHAMIDE ..................................................... 7 BLEPHAMIDE S.O.P. ......................................... 7 BLOCADREN ..................................................... 3 blood sugar diagnostic ........................................ 6 blood-glucose calib. control ................................. 6 blood-glucose meter ........................................... 6 BONIVA .............................................................. 6 bosentan ............................................................. 3 BOSULIF .......................................................... 11 bosutinib ........................................................... 11 BREO ELLIPTA .................................................. 1 BRETHINE.......................................................... 1 BREVOXYL-4 ..................................................... 4 BREVOXYL-8 ..................................................... 4 BRILINTA ........................................................... 8 brimonidine tartrate .......................................... 7 brimonidine/timolol .............................................. 7 brinzolamide ....................................................... 7 brinzolamide/brimonidine .................................... 7 bromocriptine mesylate.................................. 12 budesonide .................................................. 1, 10 BUDESONIDE .................................................. 10 bumetanide ........................................................ 3 BUMEX ............................................................... 3 BUPHENYL POWDER ..................................... 10



BUPHENYL TABLET ........................................ 10 buprenorphine ................................................... 12 bupropion hcl .................................................... 1 BUSPAR ............................................................. 2 buspirone hcl .................................................... 2 busulfan ............................................................ 11 butalb/acetaminophen/caffeine ..................... 12 butalbital/acetaminophen ............................... 12 butalbital/aspirin/caffeine ............................... 12 butoconazole nitrate ......................................... 13 BUTRANS ........................................................ 12 BYSTOLIC .......................................................... 3 BYVALSON ........................................................ 3 cabergoline ....................................................... 7 CABOMETYX ................................................... 11 cabozanitinib ..................................................... 11 cabozantinib s-malate ....................................... 11 CADUET ............................................................. 4 CAFERGOT ...................................................... 12 CALAN ................................................................ 3 CALAN SR .......................................................... 3 calcipotriene...................................................... 5 calcitriol ........................................................... 14 calcium acetate ................................................. 6 canagliflozin ........................................................ 6 canagliflozin/metformin hcl .................................. 6 CANASA ........................................................... 10 capecitabine .................................................... 11 CAPITAL W-CODEINE ..................................... 12 CAPOTEN .......................................................... 3 CAPOZIDE ......................................................... 2 captopril ............................................................ 3 captopril/hydrochlorothiazide .......................... 2 CARAFATE ...................................................... 13 carbachol ............................................................ 7 carbamazepine ................................................ 13 CARBATROL .................................................... 13 carbidopa ........................................................ 13 carbidopa/levodopa ........................................ 12 carbidopa/levodopa/entacapone ................... 12 CARDIZEM ......................................................... 3 CARDIZEM CD ................................................... 3 CARDURA .......................................................... 2 carisoprodol .................................................... 13 carisoprodol/aspirin ....................................... 13 CARMOL HC ...................................................... 5 carteolol hcl....................................................... 7 carvedilol ........................................................... 3 carvedilol phosphate ........................................... 3 CASODEX ........................................................ 11 CATAPRES ........................................................ 3 CAYSTON .......................................................... 8 CECLOR ............................................................. 8 CEENU ............................................................. 11 cefaclor .............................................................. 8 cefadroxil hydrate ............................................. 8 cefdinir ............................................................... 8 cefixime ............................................................. 8 cefpodoxime proxetil ........................................ 8 cefprozil ............................................................. 8 CEFTIN ............................................................... 8 cefuroxime axetil .............................................. 8 CEFZIL ............................................................... 8 CELEBREX ...................................................... 10 celecoxib ......................................................... 10 CELEXA ............................................................. 1 CELLCEPT ......................................................... 8 CENTANY .......................................................... 4 cephalexin monohydrate .................................. 8 ceritinib ............................................................. 11 cetirizine hcl (OTC) ........................................... 1 cetrorelix acetate ................................................ 6 CETROTIDE ....................................................... 6 cevimeline hcl ................................................. 11 chloral hydrate .................................................. 2 chlorambucil ..................................................... 11 chlordiazepoxide hcl ........................................ 2 chlordiazepoxide/clidinium br ............................ 13 chlorhexidine gluconate ................................. 12 chloroquine phosphate .................................... 9 chlorpromazine hcl ........................................... 2 chlorpropamide ................................................. 5 chlorthalidone ................................................... 3 chlorzoxazone ................................................. 13 cholestyramine/aspartame ............................... 3 CHRONULAC ................................................... 10 CIBALITH-S ........................................................ 2

CICLODAN ......................................................... 5 ciclopirox 8% solution ...................................... 5 ciclopirox olamine ............................................ 5 cilostazol ........................................................... 8 CILOXAN ............................................................ 7 cimetidine hcl .................................................. 13 CIPRO ................................................................ 8 CIPRO ORAL SUSPENSION ............................. 8 CIPRODEX ......................................................... 6 ciprofloxacin ..................................................... 8 ciprofloxacin hcl ........................................... 7, 8 ciprofloxacin hcl/dexameth .................................. 6 citalopram hydrobromide ................................. 1 CLARAVIS .......................................................... 4 clarithromycin ................................................... 8 CLARITIN (OTC) ................................................ 1 CLARITIN-D 12 HOUR ....................................... 1 CLARITIN-D 24 HOUR ....................................... 1 CLEOCIN ............................................................ 8 CLEOCIN PALMITATE ....................................... 8 CLEOCIN T......................................................... 4 CLIMARA ............................................................ 8 clindamycin hcl ................................................... 8 clindamycin palmitate solution ........................ 8 clindamycin phosphate .................................... 4 clindamycin/tretinoin ........................................... 4 CLINORIL ......................................................... 10 clobetasol propionate ....................................... 5 clobetasol propionate/emoll ............................ 5 CLOBEX ............................................................. 5 CLOMID .............................................................. 6 clomiphene citrate ............................................ 6 clomipramine hcl .............................................. 2 clonazepam ..................................................... 13 clonidine hcl ...................................................... 3 clopidogrel bisulfate ......................................... 8 clorazepate dipotassium .................................. 2 clotrimazole ....................................................... 9 clotrimazole/betamet diprop ............................ 5 clozapine ............................................................ 2 CLOZARIL .......................................................... 2 cobicistat ........................................................... 10 cobimetinib fumarate ......................................... 11 codeine phos/carisoprodol/asa ..................... 12 codeine/butalbit/acetamin/caff ....................... 12 codeine/butalbital/asa/caffein ........................ 12 codeine/promethazine hcl ................................ 4 COGENTIN ....................................................... 12 COLAZAL ......................................................... 10 colesevelam hcl .................................................. 3 COLESTID .......................................................... 3 COLESTID GRANULES ..................................... 3 colestipol ............................................................. 3 COLYTE WITH FLAVOR PACKETS ................. 10 COMBIGAN ........................................................ 7 COMBIPATCH .................................................... 8 COMBIVENT ...................................................... 1 COMBIVENT RESPIMAT ................................... 1 COMBIVIR .......................................................... 9 COMETRIQ ...................................................... 11 COMPAZINE ...................................................... 1 COMPAZINE SYRUP ......................................... 1 COMPLERA...................................................... 10 COMTAN .......................................................... 12 CONCERTA........................................................ 2 CONDYLOX........................................................ 4 COPAXONE ..................................................... 11 COPEGUS ........................................................ 10 CORDARONE .................................................... 2 CORDRAN ......................................................... 5 CORDRAN SP .................................................... 5 COREG .............................................................. 3 COREG CR ........................................................ 3 CORGARD ......................................................... 3 CORLANOR ....................................................... 4 CORTEF ........................................................... 10 CORTENEMA ................................................... 10 cortisone acetate ............................................ 10 CORTISPORIN CREAM ..................................... 5 CORTISPORIN OINTMENT ............................... 5 CORTISPORIN OPHTH SUSPENSION ............. 7 CORTISPORIN OTIC ......................................... 6 CORTONE ACETATE ...................................... 10 COSENTYX ........................................................ 5 COSOPT ............................................................ 7 COTELLIC ........................................................ 11 COUMADIN ........................................................ 7

COZAAR ............................................................. 3 CREON ............................................................. 13 CREON 36K ..................................................... 13 CRESTOR .......................................................... 3 CRINONE ........................................................... 6 crisaborole .......................................................... 5 CRIXIVAN ........................................................... 9 crizotinib ........................................................... 11 cromolyn sodium .......................................... 1, 7 crotamiton ........................................................... 5 CUPRIMINE ...................................................... 10 CUTIVATE .......................................................... 5 cyanocobalamin/fa/pyridoxine ........................... 14 CYCLESSA ......................................................... 4 cyclobenzaprine hcl ........................................ 13 CYCLOCORT ..................................................... 5 CYCLOGYL ........................................................ 7 cyclopentolate hcl ............................................. 7 cyclophosphamide ......................................... 11 cyclosporine .................................................... 7, 8 cyclosporine, modified ..................................... 8 CYSTARAN ........................................................ 7 cysteamine.......................................................... 7 cysteamine bitartrate ......................................... 13 CYTOMEL .......................................................... 7 CYTOTEC......................................................... 13 CYTOVENE ........................................................ 9 CYTOXAN ........................................................ 11 dabrafanib ......................................................... 11 DALIRESP .......................................................... 1 DALMANE .......................................................... 2 dalteparin sodium,porcine ................................... 8 danazol .............................................................. 7 DANOCRINE ...................................................... 7 DANTRIUM ....................................................... 13 dantrolene sodium .......................................... 13 dapsone ............................................................. 9 DARAPRIM ......................................................... 9 darunavir ethanolate ........................................... 9 darunavir/cobicistat ............................................. 9 dasatinib ........................................................... 11 DAYPRO .......................................................... 10 DDAVP ............................................................... 6 DECADRON ..................................................... 10 DELATESTRYL .................................................. 8 delavirdine mesylate ........................................... 9 DEL-BETA .......................................................... 5 DELTASONE .................................................... 10 DEMADEX .......................................................... 3 DEMULEN 1-50-21 ............................................. 4 DEPAKENE CAPSULES .................................. 13 DEPAKENE SYRUP ......................................... 13 DEPAKOTE ...................................................... 13 DEPAKOTE ER ................................................ 13 DEPAKOTE SPRINKLE .................................... 13 DEPEN ............................................................. 10 DEPO-TESTOSTERONE ................................... 8 DESCOVY .......................................................... 9 desipramine hcl ................................................ 2 desmopressin ................................................... 6 DESOGEN .......................................................... 4 desogestrel-ethinyl estradiol ........................... 4 desog-et estra/ethin estra ................................ 4 desonide ............................................................ 5 DESOWEN ......................................................... 5 desoximetasone ................................................ 5 desvenlafaxine ER (Ranbaxy Brand) .................. 1 DESVENLAFAXINE ER (RANBAXY BRAND) .... 1 desvenlafaxine succinate ................................. 1 DESYREL ........................................................... 1 DETROL ........................................................... 13 DETROL LA ...................................................... 13 dexamethasone ............................................... 10 DEXEDRINE ....................................................... 2 DEXEDRINE SPANSULE ................................... 2 dexmethylphenidate hcl ................................... 2 dextroamphetamine sulfate ............................. 2 dextroamphetamine tablet................................... 2 DIABETA ............................................................ 5 DIABINESE ......................................................... 5 DIAMOX SEQUELS ............................................ 7 DIASTAT .......................................................... 13 diazepam ..................................................... 2, 13 DIBENZYLINE .................................................... 2 dichlorphenamide ............................................. 13 diclofenac sodium .................................. 5, 7, 10 dicloxacillin sodium .......................................... 8



dicyclomine hcl ............................................... 13 didanosine ......................................................... 9 DIDRONEL ......................................................... 6 DIFFERIN ........................................................... 4 DIFICID ............................................................... 8 diflorasone diacetate ........................................ 5 diflorasone diacetate/emoll ................................. 5 DIFLUCAN .......................................................... 9 diflunisal .......................................................... 12 difluprednate ....................................................... 7 digoxin ............................................................... 2 DIGOXIN ORAL SOLN ....................................... 2 DILACOR XR ...................................................... 3 DILANTIN ......................................................... 13 DILANTIN CHEW TAB ...................................... 13 DILANTIN-125 .................................................. 13 DILAUDID ......................................................... 12 DILAUDID-5 ...................................................... 12 diltiazem hcl ...................................................... 3 dimethyl fumarate ............................................. 11 DIOVAN .............................................................. 3 DIOVAN HCT ...................................................... 3 diphenoxylate hcl/atrop sulf .......................... 10 dipivefrin hcl ........................................................ 7 DIPROLENE ....................................................... 5 DIPROLENE AF ................................................. 5 DIPROSONE ...................................................... 5 dipyridamole ..................................................... 8 DISALCID ......................................................... 12 disopyramide phosphate ................................. 2 disulfiram ............................................................ 2 DITROPAN XL .................................................. 13 divalproex sodium .......................................... 13 d-methorphan hb/prometh hcl ......................... 4 dofetilide ............................................................ 2 DOLOBID ......................................................... 12 DOLOPHINE HCL ............................................ 12 dolutegravir ......................................................... 9 DOMEBORO ...................................................... 6 donepezil hcl ..................................................... 1 DONNATAL ...................................................... 13 dornase alfa ...................................................... 12 dorzolamide hcl ................................................ 7 dorzolamide hcl/timolol maleat ........................ 7 DOSTINEX ......................................................... 7 DOVONEX .......................................................... 5 doxazosin mesylate .......................................... 2 doxepin hcl ........................................................ 2 doxycycline calcium ............................................ 9 doxycycline hyclate .......................................... 9 DOXYCYCLINE HYCLATE 100MG TABLET ...... 9 DOXYCYCLINE MONOHYDRATE 150MG

TABLET ........................................................ 9 DRISDOL .......................................................... 14 DRITHOCREME HP ........................................... 5 DRITHO-SCALP ................................................. 5 dronabinol ......................................................... 1 dronedarone hcl .................................................. 2 DRYSOL ............................................................. 5 DUAVEE ............................................................. 8 DUETACT ........................................................... 6 DULERA ............................................................. 1 DUONEB ............................................................ 1 DURAGESIC .................................................... 12 DUREZOL .......................................................... 7 DURICEF ............................................................ 8 dutasetride/tamsulosin ................................... 13 DYAZIDE ............................................................ 3 DYNACIN ........................................................... 9 EC-NAPROSYN ............................................... 10 EDARBI .............................................................. 3 EDARBYCLOR ................................................... 3 EDURANT .......................................................... 9 efavirenz ............................................................. 9 efavirenz/emtricitab/tenofovir .............................. 9 EFFIENT ............................................................. 8 EFUDEX ............................................................. 5 ELAVIL ............................................................... 1 ELDEPRYL ....................................................... 13 ELIDEL ............................................................... 5 ELIGARD ............................................................ 6 ELIMITE .............................................................. 5 ELIQUIS ............................................................. 7 ELMIRON ......................................................... 13 ELOCON ............................................................ 5 eltrombopag olamine .......................................... 8 elviteg/cobi/emtric/tenofo ala ............................... 9

elvitegravir/ cobicistat/emtricitabine/tenofovir disoproxil fumarate ....................................... 9

EMCYT ............................................................. 11 EMEND ............................................................... 1 EMGEL ............................................................... 4 empagliflozin ....................................................... 6 empagliflozin/linagliptin ....................................... 6 empagliflozin/metformin hcl ................................. 6 empagliflozin/metformin XR ................................ 6 emtricitab/rilpiviri/tenof ala................................. 10 emtricitab/rilpivirine/tenofovir ............................. 10 emtricitabine ....................................................... 9 emtricitabine/tenofov alafenam ........................... 9 emtricitabine/tenofovir ......................................... 9 EMTRIVA ............................................................ 9 EMVERM ............................................................ 9 enalapril maleate ............................................... 3 enalapril/hydrochlorothiazide .......................... 2 ENBREL ........................................................... 10 ENDOMETRIN .................................................... 6 enfuvirtide ........................................................... 9 enoxaparin sodium ........................................... 7 entacapone ...................................................... 12 entecavir .......................................................... 10 ENTOCORT EC ................................................ 10 ENTRESTO ........................................................ 4 enzalutamide .................................................... 11 EPCLUSA ......................................................... 10 EPIDUO .............................................................. 4 EPIDUO FORTE ................................................. 4 epinephrine ............................................... 10, 11 EPIPEN ............................................................ 10 EPIPEN JR ....................................................... 11 EPIVIR ................................................................ 9 EPIVIR HBV SOLUTION .................................. 10 EPIVIR HBV TABLET ....................................... 10 eplerenone......................................................... 3 epoetin alfa ......................................................... 7 EPZICOM ........................................................... 9 ergocalciferol .................................................. 14 ergotamine tartrate/caffeine ........................... 12 erlotinib hcl ....................................................... 11 ery e-succ/sulfisoxazole ................................... 8 ERYC .................................................................. 8 ERYGEL ............................................................. 4 ERYPED 200 ...................................................... 8 ERYPED 400 ...................................................... 8 ERY-TAB ............................................................ 8 ERYTHROCIN STEARATE ................................ 8 erythromycin base ........................................ 7, 8 erythromycin base/benz per ............................ 4 erythromycin base/ethanol .............................. 4 erythromycin ethylsuccinate ........................... 8 erythromycin stearate ...................................... 8 ESBRIET .......................................................... 12 escitalopram oxalate ........................................ 1 ESGIC .............................................................. 12 ESKALITH .......................................................... 2 esomeprazole magnesium ............................. 13 estazolam .......................................................... 2 ESTRACE ..................................................... 8, 13 ESTRADERM ..................................................... 8 estradiol ....................................................... 8, 13 estradiol/noreth ac .............................................. 8 estramustine phosphate sodium ....................... 11 ESTRATEST H.S. ............................................... 8 estrogen, con/m-progest acet ............................. 8 estrogen, ester/me-testosterone...................... 8 estrogens, conj/bazedoxifene ............................. 8 estrogens, conjugated ................................... 8, 13 estrogens, esterified............................................ 8 estropipate ........................................................ 8 eszopiclone ....................................................... 2 etanercept ......................................................... 10 ethambutol hcl .................................................. 9 ethinyl estradiol/drospirenone ......................... 4 ethosuximide ................................................... 13 ethynodiol d-ethinyl estradiol .......................... 4 etidronate disodium .......................................... 6 etodolac ........................................................... 10 etonogestrel/ethinyl estradiol .............................. 4 etoposide ......................................................... 11 etravirine ............................................................. 9 EUCRISA ............................................................ 5 EULEXIN .......................................................... 11 EURAX ............................................................... 5 everolimus .................................................... 8, 11

EVISTA ............................................................... 6 EVOCLIN ............................................................ 4 evolocumab ........................................................ 3 EVOTAZ ............................................................. 9 EVOXAC ........................................................... 11 EXELDERM ........................................................ 5 EXELON CAPSULE ............................................ 1 EXELON PATCH ................................................ 1 exemestane ..................................................... 11 EXFORGE .......................................................... 3 EXFORGE HCT .................................................. 3 ezetimibe ........................................................... 4 FABIOR .............................................................. 4 famotidine........................................................ 13 FARESTON ...................................................... 11 FARYDAK ......................................................... 11 febuxostat ........................................................... 7 FELDENE ......................................................... 10 felodipine ........................................................... 3 FEMARA ........................................................... 11 FEMHRT ............................................................. 8 fenofibrate ......................................................... 4 fenofibrate nanocrystallized ............................ 4 fenofibrate, micronized..................................... 4 FENOGLIDE ....................................................... 4 fenoprofen calcium ......................................... 10 fentanyl ............................................................ 12 fentanyl citrate lozenge .................................. 12 fesoterodine fumarate ....................................... 13 FETZIMA ............................................................ 1 fidaxomicin .......................................................... 8 filgrastim ............................................................. 8 finasteride........................................................ 13 fingolimod hcl .................................................... 11 FIORICET ......................................................... 12 FIORICET WITH CODEINE .............................. 12 FIORINAL ......................................................... 12 FIORINAL WITH CODEINE .............................. 12 FIRAZYR .......................................................... 10 FIRST-HYDROCORTISONE .............................. 5 FLAGYL .............................................................. 9 FLAGYL ER ........................................................ 9 FLAREX .............................................................. 7 flecainide acetate .............................................. 2 FLEXERIL ......................................................... 13 FLOMAX ........................................................... 13 FLONASE ........................................................... 1 FLORINEF ACETATE ....................................... 10 FLOXIN ........................................................... 6, 9 fluconazole ........................................................ 9 fludarabine phosphate ...................................... 11 fludrocortisone acetate .................................. 10 flunisolide .......................................................... 1 fluocinolone acetonide ..................................... 5 fluocinonide ...................................................... 5 fluocinonide/emollient ...................................... 5 FLUORABON BASIC ........................................ 14 fluoride ion/iron/vit a,c&d ............................... 14 fluoride ion/multivitamins .............................. 14 fluoride ion/multivits w-fe ............................... 14 fluoride ion/vit a,c&d ...................................... 14 FLUORITAB ...................................................... 13 fluorometholone................................................ 7 fluorometholone acetate ..................................... 7 fluorouracil ........................................................ 5 fluoxetine er ...................................................... 1 fluoxetine hcl ..................................................... 1 fluoxymesterone ............................................... 8 fluphenazine hcl ................................................ 2 FLURA-DROPS ................................................ 13 flurandrenolide .................................................. 5 FLURA-TABS ................................................... 13 flurazepam hcl ................................................... 2 flurbiprofen ...................................................... 10 flurbiprofen sodium .......................................... 7 flutamide .......................................................... 11 fluticasone propionate ................................. 1, 5 fluticasone/salmeterol ......................................... 1 fluticasone/vilanterol ........................................... 1 FML .................................................................... 7 FML FORTE ....................................................... 7 FML S.O.P. ......................................................... 7 FOCALIN ............................................................ 2 FOCALIN XR ...................................................... 2 FOLGARD RX .................................................. 14 folic acid .......................................................... 13 FOLIC ACID ...................................................... 13



folic acid/mu-vits-min th ................................. 14 follitropin alpha,recomb ....................................... 6 fondaparinux sodium ....................................... 8 formoterol fumarate ............................................ 1 FORTEO ............................................................. 6 FOSAMAX .......................................................... 6 FOSAMAX PLUS D ............................................ 6 FOSAMAX TABLET ............................................ 6 fosamprenavir calcium ........................................ 9 fosinopril sodium .............................................. 3 fosinopril/hydrochlorothiazide ........................ 2 FRAGMIN ........................................................... 8 FURADANTIN ..................................................... 8 furazolidone ........................................................ 8 furosemide ........................................................ 3 FUROXONE ....................................................... 8 FUZEON ............................................................. 9 gabapentin ........................................................ 13 galantamine ....................................................... 1 ganciclovir ....................................................... 7, 9 ganirelix acetate .................................................. 6 GANIRELIX ACETATE ....................................... 6 GANTRISIN ........................................................ 8 GARAMYCIN .................................................. 4, 7 gatifloxacin ........................................................ 7 GATTEX ........................................................... 10 gefitinib ............................................................. 11 gemfibrozil ........................................................ 4 gentamicin sulfate ........................................ 4, 7 Genvoya ............................................................. 9 GEODON ............................................................ 2 GIANVI ............................................................... 4 GILENYA .......................................................... 11 GILOTRIF ......................................................... 11 glatiramer acetate ........................................... 11 glimepiride ........................................................ 5 glipizide ............................................................. 5 glipizide/metformin hcl ..................................... 5 GLUCAGON EMERGENCY KIT ......................... 6 glucagon,human recombinant ............................. 6 GLUCOPHAGE .................................................. 6 GLUCOPHAGE XR ............................................ 6 GLUCOTROL ..................................................... 5 GLUCOTROL XL ................................................ 5 GLUCOVANCE ................................................... 6 glyburide ........................................................... 5 glyburide, micro/metformin hcl ....................... 6 GLYXAMBI ......................................................... 6 GOLYTELY ....................................................... 10 gonadotropin,chorionic, human ........................... 6 GONAL-F ............................................................ 6 GONAL-F RFF .................................................... 6 GRASTEK .......................................................... 1 griseofulvin suspension ....................................... 9 griseofulvin ultramicrosize .............................. 9 GRISEOFULVIN V .............................................. 9 GRIS-PEG .......................................................... 9 guanfacine hcl ................................................... 3 GYNAZOLE-1 ................................................... 13 HALCION ............................................................ 2 HALDOL ............................................................. 2 HALDOL ORAL CONC ....................................... 2 halobetasol propionate .................................... 5 haloperidol ........................................................ 2 haloperidol lactate ............................................ 2 HARVONI ......................................................... 10 hc acetate/pramoxine ....................................... 5 hc acetate/pramoxine hcl ............................... 10 hcg alpha, recombinant ....................................... 6 HEPARIN LOCK ................................................. 8 heparin sodium, porcine .................................. 8 heparin sodium, porcine/pf .............................. 8 HEP-LOCK ......................................................... 8 HEPSERA ........................................................ 10 HEXALEN ......................................................... 11 homatropine hbr ............................................... 7 HUMALOG ......................................................... 6 HUMALOG MIX 50-50 ........................................ 6 HUMALOG MIX 75-25 ........................................ 6 HUMATIN ........................................................... 9 HUMIRA ........................................................... 10 HUMULIN 70-30 ................................................. 6 HUMULIN N ........................................................ 6 HUMULIN R ........................................................ 6 HUMULIN R U-500 KWIK PEN ........................... 6 HYCAMTIN ....................................................... 11 HYCET ............................................................. 12

HYCODAN .......................................................... 4 hydralazine hcl .................................................. 3 HYDREA ........................................................... 11 hydrochlorothiazide .......................................... 3 hydrocodone bit/acetaminophen ................... 12 hydrocodone bit/acetaminophen oral elixir .. 12 hydrocodone bit/acetaminophen oral solution ... 12 hydrocodone bit/homatrop me-br .................... 4 hydrocodone bitartrate ...................................... 12 hydrocodone/chlorphen p-stirex ..................... 4 hydrocort/sal acid/sulf/shmp#1 ............................ 5 hydrocortisone ............................................ 5, 10 hydrocortisone acetate .................................. 10 hydrocortisone acetate/urea ............................ 5 hydrocortisone butyrate ................................... 5 hydrocortisone butyrate/emoll ............................. 5 hydrocortisone probutate .................................... 5 hydrocortisone valerate ................................... 5 hydromorphone hcl ........................................ 12 hydroxychloroquine sulfate ............................. 9 hydroxyurea .................................................... 11 hydroxyzine hcl ................................................. 1 hydroxyzine pamoate ....................................... 1 HYGROTON ....................................................... 3 hyoscyamine sulfate ....................................... 13 HYPER-SAL 7% ............................................... 12 HYSINGLA ER .................................................. 12 HYTRIN .............................................................. 3 HYZAAR ............................................................. 3 ibandronate ....................................................... 6 IBRANCE .......................................................... 11 ibrutinib ............................................................. 11 ibuprofen ......................................................... 10 icatibant acetate ................................................ 10 ICLUSIG ........................................................... 11 icosapent ethyl .................................................... 4 idelalisib .......................................................... 11 ILEVRO .............................................................. 7 IMBRUVICA ...................................................... 11 IMDUR ................................................................ 4 imipramine hcl .................................................. 2 imiquimod ......................................................... 8 IMITREX INJECTION ....................................... 12 IMITREX NASAL SPRAY ................................. 12 IMITREX TABLET ............................................. 12 IMPAVIDO .......................................................... 9 IMURAN ............................................................. 8 indapamide ........................................................ 3 INDERAL LA ....................................................... 3 INDERIDE-40/25 ................................................ 3 indinavir sulfate ................................................... 9 INDOCIN .......................................................... 10 INDOCIN ORAL SUSP. .................................... 10 INDOCIN SR ..................................................... 10 INDOCIN SUPPOS ........................................... 10 indomethacin .................................................. 10 ingenol ................................................................ 5 INLYTA ............................................................. 11 INSPRA .............................................................. 3 insulin glargine,hum.rec.anlog ............................ 6 insulin lispro ........................................................ 6 insulin nph hum/reg insulin hm ............................ 6 insulin nph human isophane ............................... 6 insulin npl/insulin lispro ....................................... 6 insulin regular, human ......................................... 6 INTAL ................................................................. 1 INTELENCE........................................................ 9 interferon alfa-2b, recomb. .................................. 8 interferon beta-1a ............................................. 11 interferon beta-1a/albumin ................................ 11 INTRON A .......................................................... 8 INVIRASE ........................................................... 9 INVOKAMET ....................................................... 6 INVOKANA ......................................................... 6 iodoquinol ........................................................... 9 ipratropium bromide ................................... 1, 12 ipratropium/albuterol sulfate ........................... 1 irbesartan .......................................................... 3 irbesartan/hydrochlorithiazide ......................... 3 IRESSA ............................................................ 11 ISENTRESS ....................................................... 9 ISMO .................................................................. 4 ISOCHRON ........................................................ 4 isomethept/acetaminop/dichlphn .................. 12 isoniazid ............................................................ 9 ISOPTO ATROPINE ........................................... 7 ISOPTO CARBACHOL ....................................... 7

ISOPTO CARPINE ............................................. 7 ISOPTO HOMATROPINE ................................... 7 ISORDIL ............................................................. 4 ISORDIL TITRADOSE ........................................ 4 isosorb dinit/hydralazine hcl ................................ 4 isosorbide dinitrate ........................................... 4 isosorbide mononitrate .................................... 4 isotretinoin ........................................................ 4 ISRADIPINE ....................................................... 3 isradipine IR ...................................................... 3 itraconazole ....................................................... 9 ivabradine hcl ...................................................... 4 ivacaftor ............................................................ 12 ixazomib citrate ................................................. 11 JALYN .............................................................. 13 JANUMET XR ..................................................... 5 JANUVIA ............................................................ 5 JARDIANCE ....................................................... 6 JUXTAPID .......................................................... 3 KALETRA ........................................................... 9 KALYDECO ...................................................... 12 KAYEXALATE .................................................... 6 K-DUR ................................................................ 6 KEFLEX .............................................................. 8 KENALOG .......................................................... 5 KENALOG IN ORABASE .................................. 12 KEPPRA ........................................................... 13 KETEK ................................................................ 8 ketoconazole ................................................. 5, 9 ketoprofen ....................................................... 10 ketorolac tromethamine ............................. 7, 10 ketotifen fumarate (OTC) .................................. 7 KEVEYIS .......................................................... 13 KISQALI ............................................................ 11 KLARON ............................................................. 4 KLONOPIN ....................................................... 13 KORLYM ............................................................ 6 KRISTALOSE ................................................... 10 K-TAB ................................................................. 6 KURIC ................................................................ 5 KUVAN ............................................................. 11 KWELL ............................................................... 5 KYNAMRO.......................................................... 3 labetalol hcl ....................................................... 3 LACTICARE-HC ................................................. 5 lactulose .......................................................... 10 LAMICTAL ........................................................ 13 LAMISIL .......................................................... 5, 9 LAMISIL GRANULES ......................................... 9 lamivudine ................................................... 9, 10 lamivudine/zidovudine ......................................... 9 lamotrigine ...................................................... 13 lancing device/lancets ......................................... 6 LANOXIN ............................................................ 2 lansoprazole .................................................... 13 lansoprazole/amox tr/clarith .......................... 13 LANTUS ............................................................. 6 lapatinib ditosylate ............................................ 11 LARIAM .............................................................. 9 LASIX ................................................................. 3 latanoprost ........................................................ 7 LATUDA ............................................................. 2 ledipasvir/sofosbuvir ......................................... 10 leflunomide ...................................................... 10 lenalidomide ...................................................... 11 lenvatinib mesylate ........................................... 11 LENVIMA .......................................................... 11 LESSINA ............................................................ 4 LETAIRIS ............................................................ 3 letrozole ........................................................... 11 leucovorin calcium ......................................... 11 LEUCOVORIN CALCIUM ................................. 11 LEUKERAN ...................................................... 11 LEUKINE ............................................................ 8 leuprolide ............................................................ 6 LEVAQUIN.......................................................... 9 LEVBID ............................................................. 13 levetiracetam ................................................... 13 levobunolol hcl ................................................. 7 levocetirizine ..................................................... 1 levofloxacin ....................................................... 9 levonorgestrel ................................................... 4 levonorgestrel-eth estra ................................... 4 LEVOTHROID .................................................... 7 levothyroxine sodium ....................................... 7 LEVOXYL ........................................................... 7 LEVSIN-SL ....................................................... 13



LEXAPRO ........................................................... 1 LEXIVA ............................................................... 9 LIBRAX ............................................................. 13 LIBRIUM ............................................................. 2 LIDEX ................................................................. 5 LIDEX-E .............................................................. 5 lidocaine hcl .................................................... 10 linaclotide .......................................................... 10 linagliptin ............................................................. 5 Lincosamides ...................................................... 8 lindane ............................................................... 5 linezolid ............................................................. 8 LINZESS ........................................................... 10 LIORESAL ........................................................ 13 liothyronine sodium .......................................... 7 LIPITOR .............................................................. 3 liraglutide ............................................................ 5 lisdexamfetamine dimesylate .............................. 2 lisinopril ............................................................. 3 lisinopril/hydrochlorothiazide .......................... 2 lithium carbonate .............................................. 2 lithium citrate .................................................... 2 LITHOBID ........................................................... 2 LIVALO ............................................................... 3 LO LOESTRIN FE .............................................. 4 LO MINASTRIN FE ............................................. 4 LOCOID .............................................................. 5 LOCOID LIPOCREAM ........................................ 5 LODINE ............................................................ 10 LODOSYN ........................................................ 13 lodoxamide tromethamine ................................... 7 LOESTRIN .......................................................... 4 LOESTRIN 24FE ................................................ 4 LOESTRIN FE .................................................... 4 LOFIBRA ............................................................ 4 lomitapide ........................................................... 3 LOMOTIL .......................................................... 10 lomustine .......................................................... 11 LONSURF ........................................................ 11 LO-OVRAL-28 .................................................... 4 LOPID ................................................................. 4 lopinavir/ritonavir ................................................. 9 LOPRESSOR ..................................................... 3 LOPRESSOR HCT ............................................. 3 LOPROX ............................................................. 5 loratadine (OTC ................................................. 1 lorazepam .......................................................... 2 LORAZEPAM INTENSOL ................................... 2 LORCET ........................................................... 12 LORCET PLUS ................................................. 12 LORTAB ........................................................... 12 LORTAB ELIXIR ............................................... 12 LORYNA ............................................................. 4 losartan potassium ........................................... 3 losartan/hydrochlorothiazide ........................... 3 LOTEMAX .......................................................... 7 LOTENSIN .......................................................... 3 LOTENSIN HCT ................................................. 2 loteprednol etabonate ......................................... 7 LOTREL .............................................................. 2 LOTRISONE ....................................................... 5 lovastatin ........................................................... 3 LOVAZA ............................................................. 4 LOVENOX .......................................................... 7 loxapine succinate ............................................ 2 LOXITANE .......................................................... 2 LOZOL ................................................................ 3 LUDIOMIL ........................................................... 2 lumacaftor/ivacaftor .......................................... 12 LUMIGAN ........................................................... 7 LUNESTA ........................................................... 2 LURIDE ............................................................ 13 LUTERA ............................................................. 4 LYNPARZA ....................................................... 11 LYRICA ............................................................. 13 LYSODREN ...................................................... 11 macitentan .......................................................... 3 MACROBID ........................................................ 8 MACRODANTIN ................................................. 8 malathion ........................................................... 5 maprotiline hcl .................................................. 2 maraviroc ............................................................ 9 MARINOL ........................................................... 1 MATULANE ...................................................... 11 MAVIK ................................................................ 3 MAXALT ........................................................... 12 MAXALT MLT ................................................... 12

MAXITROL ......................................................... 7 MAXZIDE ............................................................ 3 MAXZIDE-25MG ................................................. 3 mebendazole ...................................................... 9 mechlorethamine gel ........................................... 5 meclizine hcl ..................................................... 1 meclofenamate sodium .................................. 10 MECLOMEN ..................................................... 10 MEDROL .......................................................... 10 medroxyprogesterone acet .............................. 8 mefloquine hcl .................................................. 9 MEGACE .................................................... 11, 12 megestrol acetate ..................................... 11, 12 MEKINIST ......................................................... 11 MELLARIL .......................................................... 2 meloxicam ....................................................... 10 melphalan ......................................................... 11 memantine hcl ................................................... 1 memantine hcl ER .............................................. 1 memantine hcl/donepezil hcl ............................... 1 MENEST ............................................................. 8 MENOPUR ......................................................... 6 menotropins ........................................................ 6 MEPHYTON ....................................................... 8 meprobamate .................................................... 2 mercaptopurine ............................................... 11 mesalamine ..................................................... 10 mesalamine w/cleansing wipes ..................... 10 MESTINON ......................................................... 1 METADATE CD .................................................. 2 METADATE ER .................................................. 2 METAGLIP ......................................................... 5 metaproterenol sulfate ..................................... 1 metaxalone ...................................................... 13 metformin hcl .................................................... 6 meth/meth blue/ba/salicy/hyos ........................ 8 methadone hcl ................................................ 12 Methadone hcl ................................................. 12 methadone hcl injection solution .................. 12 methazolamide .................................................. 7 METHERGINE .................................................... 4 methimazole ...................................................... 7 METHITEST ....................................................... 8 methocarbamol ............................................... 13 methotrexate ..................................................... 10 methotrexate sodium ................................ 10, 11 METHOTREXATE TABLET .............................. 11 METHOTREXATE VIAL .................................... 11 methoxsalen ....................................................... 5 methoxsalen, rapid ........................................... 5 methyldopa........................................................ 3 methylergonovine maleate ............................... 4 METHYLIN CHEW TAB ...................................... 2 METHYLIN SOLN ............................................... 2 methylphenidate ER suspension ......................... 2 methylphenidate hcl ......................................... 2 methylprednisolone ........................................ 10 methyltestosterone ........................................... 8 metipranolol ...................................................... 7 metolazone ........................................................ 3 metoprolol succinate ........................................ 3 metoprolol tartrate ............................................ 3 metoprolol/hctz ................................................. 3 METROCREAM .................................................. 4 METROGEL-VAGINAL ..................................... 13 METROLOTION ................................................. 4 metronidazole ......................................... 4, 9, 13 MEVACOR ......................................................... 3 mexiletine hcl .................................................... 2 MEXITIL .............................................................. 2 miconazole nitrate .......................................... 13 MICRO-K ............................................................ 6 MICRONASE ...................................................... 5 MICROZIDE........................................................ 3 midodrine hcl .................................................... 4 MIDRIN ............................................................. 12 mifepristone ........................................................ 6 MIGERGOT ...................................................... 12 MILLIPRED ....................................................... 10 MILLIPRED DP ................................................. 10 milnacipran hcl .................................................. 11 miltefoside .......................................................... 9 MILTOWN ........................................................... 2 MINIPRESS ........................................................ 2 MINOCIN ............................................................ 9 minocycline hcl ................................................. 9 mipomersen sodium ............................................ 3

mirabegron........................................................ 13 MIRALAX .......................................................... 10 MIRAPEX ......................................................... 12 MIRCETTE ......................................................... 4 mirtazapine ........................................................ 1 misoprostol ..................................................... 13 mitotane ............................................................ 11 MOBIC .............................................................. 10 modafinil ............................................................ 2 moexipril hcl ...................................................... 3 moexipril/hydrochlorothiazide ......................... 2 mometasone furoate ..................................... 1, 5 mometasone/formoterol ...................................... 1 MONISTAT 3 .................................................... 13 MONOKET.......................................................... 4 MONOPRIL ......................................................... 3 MONOPRIL HCT ................................................ 2 montelukast sodium ......................................... 1 MORGIDOX ........................................................ 9 MORGIDOX 100MG CAPSULE .......................... 9 MORGIDOX 50MG CAPSULE ............................ 9 morphine sulfate ............................................. 12 MOTRIN ........................................................... 10 MOVANTIK ....................................................... 10 moxifloxacin hcl .............................................. 7, 9 MS CONTIN ...................................................... 12 MSIR ................................................................. 12 mth/me blue/salicy/na phos/hyo .......................... 8 MUCOMYST-10 ................................................ 12 MULTAQ ............................................................. 2 mupirocin .......................................................... 4 mupirocin calcium ......................................... 4, 12 MYAMBUTOL ..................................................... 9 MYCELEX .......................................................... 9 MYCIFRADIN ..................................................... 9 MYCOLOG II ...................................................... 5 mycophenolate mofetil ..................................... 8 MYCOSTATIN ................................................ 5, 9 MYLERAN ........................................................ 11 MYORISAN ......................................................... 4 MYRBETRIQ .................................................... 13 MYSOLINE ....................................................... 13 na sulfacetm/prednis sp ................................... 7 na sulfacetm/prednisol ac ................................... 7 nabumetone .................................................... 10 nadolol ............................................................... 3 naftifine hcl ........................................................ 5 NAFTIN ............................................................... 5 NALFON CAPSULES ....................................... 10 NALFON TABLETS .......................................... 10 naloxegol oxalate .............................................. 10 naltrexone hcl ................................................... 2 NAMENDA .......................................................... 1 NAMENDA XR .................................................... 1 NAMZARIC ......................................................... 1 NAPROSYN ...................................................... 10 naproxen ......................................................... 10 naproxen sodium ............................................ 10 naratriptan ....................................................... 12 NARCAN ............................................................ 2 Narcotic Withdrawal Therapy Agents ................ 12 NARDIL .............................................................. 1 NASACORT AQ .................................................. 1 NASAREL ........................................................... 1 NASONEX .......................................................... 1 nateglinide ......................................................... 5 NATURE-THROID .............................................. 7 NAVANE ............................................................. 2 nebivolol hcl ........................................................ 3 NEBUPENT ........................................................ 9 nedocromil sodium .............................................. 7 needles, insulin disp., safety ............................. 12 nelfinavir mesylate .............................................. 9 neo/polymyx b sulf/dexameth .......................... 7 neomy sulf/bacitrac zn/poly/hc ........................ 7 neomy sulf/polymyx b sulf/hc ...................... 5, 6, 7 neomycin sulfate............................................... 9 neomycin/bacitra/polymyxin/hc ........................... 5 neomycin/bacitracin/polymyxin ....................... 7 neomycin/polymyxn b/gramicidin ................... 7 NEO-POLYCIN HC OPHTH OINTMENT ............ 7 NEORAL ............................................................. 8 NEOSPORIN OPHTH DROPS ........................... 7 NEOSPORIN OPHTH OINTMENT ..................... 7 neostigmine bromide ........................................... 1 nepafenac ........................................................... 7 NEPTAZANE ...................................................... 7



netupitant/palonosetron hcl ................................. 1 NEULASTA ......................................................... 8 NEUPOGEN ....................................................... 8 NEUPRO .......................................................... 13 NEURONTIN .................................................... 13 NEVANAC .......................................................... 7 nevirapine .......................................................... 9 nevirapine ER .................................................... 9 NEXAVAR ........................................................ 11 NEXIUM ............................................................ 13 niacin ................................................................. 4 NIASPAN ............................................................ 4 NICARDIPINE ..................................................... 3 nicardipine hcl .................................................. 3 nifedipine ........................................................... 3 NILANDRON..................................................... 11 nilotinib hydrochloride ....................................... 11 nilutamide ........................................................ 11 nimodipine ........................................................ 3 NIMOTOP ........................................................... 3 NINLARO .......................................................... 11 nintedanib esylate ............................................. 12 NITRO-BID ......................................................... 4 NITRO-DUR ....................................................... 4 nitrofurantoin ....................................................... 8 nitrofurantoin macrocrystal ............................. 8 nitrofurantoin/nitrofuran mac .......................... 8 nitroglycerin ...................................................... 4 NITROLINGUAL ................................................. 4 NITROSTAT ....................................................... 4 nizatidine ......................................................... 13 NIZORAL ........................................................ 5, 9 NOCTEC ............................................................ 2 NOLVADEX ...................................................... 11 NORCO ............................................................ 12 NORDETTE-28 ................................................... 4 NORDITROPIN ................................................... 6 NORDITROPIN FLEXPRO ................................. 6 NORDITROPIN NORDIFLEX ............................. 6 norelgestromin/ethin.estradiol ........................ 4 noreth a-et estra/fe fumarate ............................ 4 norethindrone ................................................... 4 norethindrone acetate ...................................... 8 norethindrone ac-eth estradiol ........................ 8 norethindrone a-e estradiol .............................. 4 norethindrone-ethinyl estrad ........................... 4 norethindrone-mestranol ................................. 4 NORFLEX ......................................................... 13 NORGESIC FORTE.......................................... 13 norgestimate-ethinyl estradiol ......................... 4 norgestrel-ethinyl estradiol .............................. 4 NORINYL 1+35 ................................................... 4 NORINYL 1+50 ................................................... 4 NORPACE .......................................................... 2 NORPACE CR .................................................... 2 NORPRAMIN ...................................................... 2 NOR-Q-D ............................................................ 4 nortriptyline hcl ................................................. 2 NORVASC .......................................................... 3 NORVIR .............................................................. 9 NOVAREL .......................................................... 6 NOVOFINE 32 PEN NEEDLE ........................... 12 NUCYNTA ........................................................ 12 NUCYNTA ER .................................................. 12 NULYTELY WITH FLAVOR PACKS ................. 10 NUVARING ......................................................... 4 NYDRAZID ......................................................... 9 nystatin .......................................................... 5, 9 nystatin/triamcin ............................................... 5 OCELLA ............................................................. 4 OCL .................................................................. 10 octreotide acetate ........................................... 12 OCUFEN ............................................................ 7 OCUFLOX .......................................................... 7 OCUPRESS ....................................................... 7 ODEFSEY ........................................................ 10 ODOMZO ......................................................... 11 OFEV ................................................................ 12 ofloxacin .................................................... 6, 7, 9 OFORTA ........................................................... 11 OGEN ................................................................. 8 olanzapine ......................................................... 2 olanzapine ODT ................................................. 2 olanzapine/fluoxetine ....................................... 1 olaparib ............................................................. 11 olmesartan medoxomil ..................................... 3 olmesartan/amlodipin/hcthiazid....................... 3

olmesartan/hydrochlorothiazide ...................... 3 olodaterol hcl ...................................................... 1 olopatadine hcl .................................................... 7 OLUX .................................................................. 5 omega-3 acid ethyl esters ................................ 4 omeprazole ...................................................... 13 omeprazole magnesium ................................. 13 OMNICEF ........................................................... 8 OMNIPRED ........................................................ 7 OMNITROPE ...................................................... 6 ondansetron ...................................................... 1 ondansetron hcl ................................................ 1 ondansetron hcl solution ................................. 1 ONEXTON .......................................................... 4 OPSUMIT ........................................................... 3 OPTICROM ........................................................ 7 OPTIPRANOLOL ................................................ 7 OPTIVAR ............................................................ 7 ORALAIR ............................................................ 1 ORAMORPH SR ............................................... 12 ORAPRED ........................................................ 10 ORFADIN ......................................................... 12 ORINASE ........................................................... 5 ORKAMBI ......................................................... 12 orphenadrine citrate ....................................... 13 orphenadrine/aspirin/caffeine ........................ 13 ORSYTHIA ......................................................... 4 ORTHO EVRA .................................................... 4 ORTHO MICRONOR .......................................... 4 ORTHO TRI-CYCLEN ........................................ 4 ORTHO TRI-CYCLEN LO ................................... 4 ORTHO-CEPT .................................................... 4 ORTHO-CYCLEN ............................................... 4 ORTHO-NOVUM ................................................ 4 ORUVAIL .......................................................... 10 oseltamivir phosphate ...................................... 9 osimertinib mesylate ......................................... 11 OTEZLA .............................................................. 5 OTICIN HC ......................................................... 6 OTREXUP ........................................................ 10 OVACE PLUS SUSPENSION ............................. 5 OVIDE ................................................................ 5 OVIDREL ............................................................ 6 oxaprozin ......................................................... 10 oxazepam .......................................................... 2 oxcarbazepine ................................................. 13 OXSORALEN ..................................................... 5 OXSORALEN-ULTRA ......................................... 5 oxybutynin chloride ........................................ 13 oxycodone hcl ................................................. 12 oxycodone hcl/acetaminophen ...................... 12 oxycodone hcl/aspirin .................................... 12 OXYCONTIN .................................................... 12 palbociclib ......................................................... 11 PAMELOR .......................................................... 2 PANCRELIPASE .............................................. 13 PANDEL ............................................................. 5 panobinostat lactate .......................................... 11 pantoprazole sodium ...................................... 13 PARAFON FORTE DSC ................................... 13 PARCOPA ........................................................ 12 paricalcitol ......................................................... 6 PARLODEL....................................................... 12 PARNATE ........................................................... 1 paromomycin sulfate ........................................ 9 paroxetine hcl ................................................... 1 PATADAY ........................................................... 7 PATANOL ........................................................... 7 PATHOCIL .......................................................... 8 PAXIL ................................................................. 1 pazopanib hydrochloride ................................... 11 PCE .................................................................... 8 PEDIAPRED ..................................................... 10 PEDIAZOLE........................................................ 8 peg 3350/na sulf,bicarb,cl/kcl ........................ 10 PEGASYS ........................................................ 10 PEGASYS PROCLICK ..................................... 10 pegfilgrastim ....................................................... 8 peginterferon alfa-2a ......................................... 10 peginterferon beta-1a ........................................ 11 pegvisomant ....................................................... 6 pemirolast potassium .......................................... 7 penicillamine ..................................................... 10 penicillin v potassium ...................................... 8 pentamidine isethionate ...................................... 9 pentosan polysulfate sodium ............................. 13 pentoxifylline ..................................................... 7

PEPCID ............................................................ 13 p-ephed hcl/cetirizine hcl (OTC) ...................... 1 p-ephed sul/loratadine ...................................... 1 PERCOCET ...................................................... 12 PERCODAN ..................................................... 12 PERCOLONE ................................................... 12 PERFOROMIST ................................................. 1 PERIDEX .......................................................... 12 PERISOL .......................................................... 12 permethrin ......................................................... 5 perphenazine ..................................................... 2 PERSANTINE ..................................................... 8 phenazopyridine hcl ....................................... 13 phenelzine sulfate ............................................... 1 PHENERGAN ..................................................... 1 PHENERGAN VC ............................................... 4 PHENERGAN VC W/CODEINE .......................... 4 PHENERGAN W/CODEINE ................................ 4 PHENERGAN W/DEXTROMETHORPHAN ........ 4 phenobarbital .................................................... 2 PHENOBARBITAL .............................................. 2 phenoxybenzamine hcl .................................... 2 phenylephrine hcl/cod/prometh ....................... 4 phenylephrine hcl/prometh hcl ........................ 4 PHENYTEK ...................................................... 13 phenytoin......................................................... 13 phenytoin sodium extended .......................... 13 PHOSLO ............................................................. 6 PHRENILIN ....................................................... 12 PHRENILIN FORTE .......................................... 12 phytonadione ...................................................... 8 PICATO .............................................................. 5 pilocarpine hcl ............................................ 7, 11 pindolol .............................................................. 3 pioglitazone hcl ................................................. 6 pioglitazone hcl/metformin hcl ............................. 6 pioglitazone/glimepiride ................................... 6 pirfenidone ........................................................ 12 piroxicam ......................................................... 10 PLAN B ONE-STEP ............................................ 4 PLAQUENIL ........................................................ 9 PLAVIX ............................................................... 8 PLAVIX 300MG .................................................. 8 PLEGRIDY........................................................ 11 PLEGRIDY PEN ............................................... 11 PLENDIL ............................................................. 3 PLETAL .............................................................. 8 podofilox ........................................................... 4 POLYCILLIN ....................................................... 8 POLYCIN-B ........................................................ 7 polyethylene glycol 3350 ................................ 10 polymyxin b sulfate/tmp ................................... 7 POLYTRIM ......................................................... 7 POLY-VI-FLOR ................................................. 14 POLY-VI-FLOR W/IRON ................................... 14 pomalidamide ................................................... 11 POMALYST ...................................................... 11 ponatinib ........................................................... 11 potassium chloride ........................................... 6 potassium iodide .............................................. 7 POTASSIUM IODIDE ......................................... 7 POTIGA ............................................................ 13 PRALUENT ......................................................... 3 pramipexole di-hcl .......................................... 12 pramlintide acetate.............................................. 5 PRAMOSONE .................................................... 5 PRANDIMET ....................................................... 6 PRANDIN ........................................................... 5 prasugrel hcl ....................................................... 8 PRAVACHOL ...................................................... 3 pravastatin sodium ........................................... 3 praziquantel ........................................................ 9 prazosin hcl ....................................................... 2 PRECOSE .......................................................... 5 PRED FORTE ..................................................... 7 PRED MILD ........................................................ 7 PREDNISOL ....................................................... 7 prednisolone ................................................... 10 prednisolone acetate ........................................ 7 prednisolone sod phosphate ..................... 7, 10 prednisone ...................................................... 10 PREDNISONE INTENSOL ............................... 10 pregabalin ......................................................... 13 PREGNYL .......................................................... 6 PREMARIN ................................................... 8, 13 PREMPHASE ..................................................... 8 PREMPRO.......................................................... 8



prenatal vit 15/iron cb/fa/dss .......................... 14 prenatal vit 16/iron cb/fa/dss .......................... 14 prenatal vit 18/iron cb/fa/dss .......................... 14 PRENAVITE ..................................................... 14 PREVACID ....................................................... 13 PREVPAC ........................................................ 13 PREZCOBIX ....................................................... 9 PREZISTA .......................................................... 9 PRILOSEC ....................................................... 13 PRILOSEC OTC ............................................... 13 PRIMAQUINE ..................................................... 9 primaquine phosphate ........................................ 9 primidone ........................................................ 13 PRIMSOL ........................................................... 8 PRINIVIL ............................................................. 3 PRINZIDE ........................................................... 2 PRISTIQ ............................................................. 1 PROAIR HFA ...................................................... 1 PROAIR RESPICLICK ........................................ 1 PROAMATINE .................................................... 4 probenecid ........................................................ 7 procainamide hcl .............................................. 2 procarbazine hcl ............................................... 11 PROCARDIA ...................................................... 3 PROCARDIA XL ................................................. 3 PROCHIEVE....................................................... 6 prochlorperazine edisylate .................................. 1 prochlorperazine maleate ................................ 1 PROCRIT ........................................................... 7 PROCTOCORT ................................................ 10 PROCTOCREAM-HC ....................................... 10 PROCTOFOAM-HC .......................................... 10 PROCTO-KIT .................................................... 10 PROCYSBI ....................................................... 13 PROFASI ............................................................ 6 progesterone, micronized ............................... 6, 8 PROGRAF .......................................................... 8 PROLIXIN ........................................................... 2 PROLOPRIM ...................................................... 8 PROMACTA ....................................................... 8 promethazine hcl .............................................. 1 PROMETRIUM ................................................... 8 PRONESTYL ...................................................... 2 propafenone hcl ................................................ 2 PROPINE ........................................................... 7 propranolol hcl .................................................. 3 propranolol/hydrochlorothiazid ....................... 3 propylthiouracil .................................................... 7 PROPYLTHIOURACIL ........................................ 7 PROSCAR ........................................................ 13 PROSED-DS ...................................................... 8 PROSOM ............................................................ 2 PROSTIGMIN ..................................................... 1 PROTONIX ....................................................... 13 PROTOPIC ......................................................... 5 PROVERA .......................................................... 8 PROVIGIL ........................................................... 2 PROZAC ............................................................. 1 PROZAC WEEKLY ............................................. 1 PULMICORT FLEXHALER ................................. 1 PULMICORT RESPULES ................................... 1 PULMOZYME ................................................... 12 PURINETHOL ................................................... 11 PURIXAN .......................................................... 11 pyrazinamide ..................................................... 9 PYRAZINAMIDE ................................................. 9 PYRIDIUM ........................................................ 13 pyridostigmine bromide ................................... 1 pyrimethamine .................................................... 9 QNASL ............................................................... 1 QNASL CHILDREN ............................................ 1 QUALAQUIN....................................................... 9 QUESTRAN LIGHT ............................................ 3 quetiapine fumarate .......................................... 2 QUILLICHEW ER ............................................... 2 QUILLIVANT XR ................................................. 2 QUINAGLUTE .................................................... 2 quinapril hcl ...................................................... 3 quinapril/hydrochlorothiazide .......................... 2 QUINIDEX .......................................................... 2 quinidine gluconate .......................................... 2 quinidine sulfate ............................................... 2 quinine sulfate .................................................. 9 QVAR ................................................................. 1 RAGWITEK ........................................................ 1 raloxifene hcl ..................................................... 6 raltegravir potassium........................................... 9

ramipril .............................................................. 3 RANEXA ............................................................. 4 ranitidine hcl ................................................... 13 ranolazine ........................................................... 4 RAPAMUNE ....................................................... 8 rasagiline mesylate ......................................... 13 RAYALDEE......................................................... 6 RAZADYNE ........................................................ 1 RAZADYNE ER .................................................. 1 REBETOL ......................................................... 10 REBIF ............................................................... 11 REBIF REBIDOSE ............................................ 11 REDERM ............................................................ 5 regorafenib ....................................................... 11 REGRANEX........................................................ 6 RELAFEN ......................................................... 10 REMERON ......................................................... 1 RENAGEL .......................................................... 6 RENVELA ........................................................... 6 repaglinide......................................................... 5 repaglinide/metformin hcl ................................ 6 REPATHA ........................................................... 3 REPRONEX........................................................ 6 REQUIP ............................................................ 13 REQUIP XL....................................................... 13 RESCRIPTOR .................................................... 9 reserpine ........................................................... 3 RESTASIS .......................................................... 7 RESTASIS MULTIDOSE .................................... 7 RESTORIL .......................................................... 2 RETIN-A MICRO .............................................. 15 RETROVIR ......................................................... 9 REVATIO TABLET.............................................. 3 REVIA ................................................................. 2 REVLIMID ......................................................... 11 REXULTI ............................................................ 2 REYATAZ ........................................................... 9 RHEUMATREX ................................................. 10 ribavirin ....................................................... 9, 10 RIFADIN ............................................................. 9 RIFAMATE ......................................................... 9 rifampin ............................................................. 9 rifampin/isoniazid ............................................. 9 rifaximin .............................................................. 9 rilpivirine ............................................................. 9 riociguat .............................................................. 3 RIOMET .............................................................. 6 RISPERDAL ....................................................... 2 RISPERDAL M-TAB ........................................... 2 risperidone ........................................................ 2 RITALIN .............................................................. 2 RITALIN LA......................................................... 2 RITALIN-SR ........................................................ 2 ritonavir ............................................................... 9 rivaroxaban ......................................................... 7 rivastigmine ....................................................... 1 rivastigmine tartrate ......................................... 1 rizatriptan benzoate ........................................ 12 ROBAXIN ......................................................... 13 ROBAXIN-750 .................................................. 13 ROCALTROL .................................................... 14 roflumilast ........................................................... 1 ROMYCIN ........................................................... 7 ropinirole hcl ................................................... 13 rosuvastatin calcium ........................................ 3 rotigotine ........................................................... 13 ROWASA .......................................................... 10 ROXANOL ........................................................ 12 ROXICET .......................................................... 12 ROXICODONE ................................................. 12 ROXICODONE INTENSOL............................... 12 RYTHMOL .......................................................... 2 RYTHMOL SR .................................................... 2 sacubitril/valsartan .............................................. 4 SALAGEN ......................................................... 11 salmeterol xinafoate ............................................ 1 salsalate .......................................................... 12 SANDIMMUNE ................................................... 8 SANDOSTATIN ................................................ 12 SAPHRIS ............................................................ 2 sapropterin dihydrochloride ............................... 11 saquinavir mesylate ............................................ 9 sargramostim ...................................................... 8 SAVELLA .......................................................... 11 SCALACORT ...................................................... 5 SCALACORT DK ................................................ 5 SEASONALE ...................................................... 4

SECTRAL ........................................................... 3 secukinumab ....................................................... 5 selegiline hcl ................................................... 13 selenium sulfide ................................................ 5 selexipag ............................................................ 3 SELSUN RX ....................................................... 5 SELZENTRY ....................................................... 9 SEPTRA ............................................................. 8 SEPTRA DS ....................................................... 8 SERAX ............................................................... 2 SEREVENT DISKUS .......................................... 1 SEROPHENE ..................................................... 6 SEROQUEL ........................................................ 2 SERPASIL .......................................................... 3 sertraline hcl ..................................................... 1 sevelamer carbonate .......................................... 6 sevelamer hcl ...................................................... 6 SFROWASA ..................................................... 10 short ragweed pollen extract ............................... 1 sildenafil citrate ............................................ 3, 6 SILENOR ............................................................ 2 SILVADENE ........................................................ 5 silver sulfadiazine ............................................. 5 SIMBRINZA ........................................................ 7 simvastatin ........................................................ 3 simvastatin (80mg only) ................................... 3 SINEMET 25-100 .............................................. 12 SINEMET CR .................................................... 12 SINEQUAN ......................................................... 2 SINGULAIR ........................................................ 1 sirolimus ............................................................ 8 sitagliptin phosphate ........................................... 5 SIVEXTRO.......................................................... 8 SKELAXIN ........................................................ 13 SLO-NIACIN ....................................................... 4 sod chloride/nahco3/kcl/peg's ....................... 10 sodium chloride for inhalation ........................... 12 sodium fluoride ............................................... 13 sodium phenylbutyrate .................................. 10 sodium polystyrene sulfonate ......................... 6 sofosbuvir/velpatasvir ....................................... 10 solifenacin succindate ....................................... 13 SOMA ............................................................... 13 SOMA COMPOUND ......................................... 13 SOMA COMPOUND WITH CODEINE .............. 12 somatropin .......................................................... 6 SOMAVERT ........................................................ 6 SONATA ............................................................. 2 sonidegib phosphate ......................................... 11 sorafenib tosylate .............................................. 11 SORIATANE ....................................................... 5 sotalol hcl .......................................................... 3 SOTRET ............................................................. 4 SPIRIVA ............................................................. 1 SPIRIVA RESPIMAT .......................................... 1 spironolactone .................................................. 3 SPORANOX ....................................................... 9 SPRYCEL ......................................................... 11 SRONYX ............................................................ 4 SSRI & 5HT1A Partial Agonist Antidepressants .. 1 SSRI, Serotonin Receptor Modulator

Antidepressants ............................................ 1 STAGESIC-10 .................................................. 12 STALEVO ......................................................... 12 STARLIX ............................................................. 5 stavudine ........................................................... 9 STELARA ......................................................... 10 STELAZINE ........................................................ 2 STIOLTO RESPIMAT ......................................... 1 STIVARGA........................................................ 11 STRATTERA ...................................................... 2 STRENSIQ ....................................................... 12 STRIBILD ........................................................... 9 STRIVERDI RESPIMAT ..................................... 1 sucralfate ......................................................... 13 sulconazole nitrate .............................................. 5 SULFAC ............................................................. 7 sulfacetamide sodium ................................. 4, 5, 7 sulfadiazine ....................................................... 8 SULFADIAZINE .................................................. 8 sulfamethoxazole/trimethoprim ....................... 8 sulfanilamide ..................................................... 13 sulfasalazine ................................................... 10 sulfisoxazole acetyl ............................................. 8 sulindac ........................................................... 10 sumatriptan ..................................................... 12 sumatriptan succinate .................................... 12



sunitinib malate ................................................. 11 SUPRAX ............................................................. 8 SUSTIVA ............................................................ 9 SUTENT ........................................................... 11 suvorexant .......................................................... 2 SYEDA ............................................................... 4 SYMBICORT ...................................................... 1 SYMBYAX .......................................................... 1 SYMLIN .............................................................. 5 SYMLINPEN 120 ................................................ 5 SYMLINPEN 60 .................................................. 5 SYMMETREL ................................................... 12 SYNALAR ........................................................... 5 SYNJARDY ........................................................ 6 SYNJARDY XR ................................................... 6 SYNTHROID....................................................... 7 syringes & needles ............................................. 6 tacrolimus ........................................................... 5 tacrolimus anhydrous ...................................... 8 tadalafil ............................................................... 3 TAFINLAR ........................................................ 11 TAGAMET ........................................................ 13 TAGRISSO ....................................................... 11 TAKE ACTION .................................................... 4 TALADINE ........................................................ 13 TAMBOCOR ....................................................... 2 TAMIFLU ............................................................ 9 tamoxifen citrate ............................................. 11 tamsulosin hcl ................................................. 13 TAPAZOLE ......................................................... 7 tapentadol ......................................................... 12 tapentadol hcl ER ............................................. 12 TARCEVA ......................................................... 11 TARGRETIN ................................................. 5, 11 TASIGNA .......................................................... 11 tazarotene ........................................................... 5 TAZORAC .......................................................... 5 tazorotene foam .................................................. 4 TECFIDERA ..................................................... 11 tedizolid phosphate ............................................. 8 teduglutide [rDNA origin] ................................... 10 TEGRETOL ...................................................... 13 TEGRETOL XR ................................................ 13 telbivudine ........................................................ 10 telithromycin ....................................................... 8 telotristat ........................................................... 10 temazepam ........................................................ 2 TEMODAR ........................................................ 11 TEMOVATE ........................................................ 5 TEMOVATE EMOLLIENT ................................... 5 temozolomide .................................................. 11 TENEX ................................................................ 3 tenofovir disoproxil fumarate ............................... 9 TENORETIC 100 ................................................ 3 TENORETIC 50 .................................................. 3 TENORMIN ........................................................ 3 terazosin hcl ...................................................... 3 terbinafine hcl ................................................. 5, 9 terbutaline sulfate ............................................. 1 teriparatide .......................................................... 6 testosterone 1% ................................................ 8 testosterone cypionate ..................................... 8 testosterone enantate ....................................... 8 testosterone gel 1.62% ....................................... 8 testosterone solution ........................................... 8 TESTRED ........................................................... 8 tetrabenazine .................................................... 11 tetracycline hcl .................................................. 9 TEXACORT ........................................................ 5 thalidomide ......................................................... 9 THALITONE ....................................................... 3 THALOMID ......................................................... 9 THEO-24 ............................................................ 1 theophylline anhydrous ................................... 1 THERMAZENE ................................................... 5 thioguanine ..................................................... 11 THIOGUANINE ................................................. 11 thioridazine hcl ................................................. 2 thiothixene ........................................................ 2 THORAZINE ....................................................... 2 thyroid, pork ........................................................ 7 TIAZAC ............................................................... 3 ticagrelor ............................................................. 8 TIKOSYN ............................................................ 2 timolol ................................................................. 7 timolol maleate .............................................. 3, 7 TIMOPTIC .......................................................... 7

TIMOPTIC-XE ..................................................... 7 timothy grass pollen extract ................................ 1 tiotropium br/olodaterol hcl .................................. 1 tiotropium bromide .............................................. 1 tipranavir ............................................................. 9 tipranavir/vitamin e tpgs ...................................... 9 TIVICAY .............................................................. 9 tizanidine hcl ................................................... 13 TOBI ................................................................... 9 TOBI PODHALER ............................................... 9 TOBRADEX ........................................................ 7 tobramycin for inhalation ................................. 9 tobramycin sulfate ............................................ 7 tobramycin sulfate/dexameth .......................... 7 tobramycin/lotepred etab .................................... 7 TOBREX ............................................................. 7 tofacitinib .......................................................... 11 tofacitinib XR ..................................................... 11 TOFRANIL .......................................................... 2 tolazamide ......................................................... 5 tolbutamide ....................................................... 5 TOLECTIN 600 ................................................. 10 TOLINASE .......................................................... 5 tolmetin sodium .............................................. 10 tolterodine tartrate .......................................... 13 TOPAMAX ........................................................ 13 TOPAMAX SPRINKLE ...................................... 13 TOPICORT ......................................................... 5 TOPICORT LP .................................................... 5 topiramate ......................................................... 13 topotecan hcl .................................................... 11 TOPROL XL........................................................ 3 TORADOL ........................................................ 10 toremifene citrate .............................................. 11 torsemide .......................................................... 3 TOUJEO ............................................................. 6 TOVIAZ ............................................................. 13 TRACLEER......................................................... 3 TRADJENTA ....................................................... 5 tramadol hcl .................................................... 12 tramadol hcl/acetaminophen ......................... 12 trametinib dimethyl sulfoxide ............................. 11 TRANDATE ........................................................ 3 trandolapril ........................................................ 3 TRANXENE T-TAB ............................................. 2 tranylcypromine sulfate ................................... 1 TRAVATAN......................................................... 7 TRAVATAN Z ..................................................... 7 travoprost ............................................................ 7 trazodone hcl .................................................... 1 TRENTAL ........................................................... 7 tretinoin ............................................................. 11 TREXALL .......................................................... 11 TRIADVANCE ................................................... 14 triamcinolone acetonide ......................... 1, 5, 12 triamterene/hydrochlorothiazid ....................... 3 TRIAZ ................................................................. 4 triazolam ............................................................ 2 TRIBENZOR ....................................................... 3 TRICOR .............................................................. 4 TRIDERM ........................................................... 5 TRIDESILON ...................................................... 5 trifluoperazine hcl ............................................. 2 trifluridine .......................................................... 7 TRIGLIDE 160MG .............................................. 4 TRIGLIDE 50MG ................................................ 4 trihexyphenidyl hcl ......................................... 12 TRILAFON .......................................................... 2 TRILEPTAL....................................................... 13 trimethoprim ...................................................... 8 TRI-NORINYL ..................................................... 4 TRINTELLIX ....................................................... 1 TRIUMEQ ........................................................... 9 TRI-VI-FLOR W/IRON ...................................... 14 TRIZIVIR ............................................................. 9 TROKENDI XR ................................................. 13 TRUSOPT .......................................................... 7 TRUVADA .......................................................... 9 TUSSIONEX ....................................................... 4 TYBOST ........................................................... 10 TYKERB ........................................................... 11 TYLENOL-CODEINE ........................................ 12 TYZEKA ............................................................ 10 ULORIC .............................................................. 7 ULTRACET ....................................................... 12 ULTRAM ........................................................... 12 ULTRASE ......................................................... 13

ULTRASE MT ................................................... 13 ULTRAVATE ....................................................... 5 UNIPHYL ............................................................ 1 UNIRETIC ........................................................... 2 UNIVASC ............................................................ 3 UPTRAVI ............................................................ 3 URECHOLINE .................................................. 11 URETRON D-S ................................................... 8 uridine triacetate ............................................... 12 URIN D.S. ........................................................... 8 UROXATRAL .................................................... 13 URSO ............................................................... 10 URSO FORTE .................................................. 10 ursodiol ........................................................... 10 ustekinumab ..................................................... 10 VAGIFEM ......................................................... 13 valacyclovir hcl ................................................. 9 VALCHLOR ........................................................ 5 VALISONE .......................................................... 5 VALIUM .............................................................. 2 valproate sodium ............................................ 13 valproic acid .................................................... 13 valsartan ............................................................ 3 valsartan/hydrochlorothiazide ......................... 3 VALTREX ........................................................... 9 VANCOCIN ......................................................... 9 vancomycin hcl ................................................. 9 VANDAZOLE .................................................... 13 VANOS ............................................................... 5 VANOXIDE-HC ................................................... 4 VANSPAR .......................................................... 2 VANTIN .............................................................. 8 VASCEPA ........................................................... 4 VASERETIC ....................................................... 2 VASOCIDIN ........................................................ 7 VASOTEC .......................................................... 3 V-CILLIN K.......................................................... 8 VECTICAL ........................................................ 14 vemurafenib ...................................................... 11 VENCLEXTA .................................................... 11 venetoclax ........................................................ 11 VENTOLIN HFA .................................................. 1 VEPESID .......................................................... 11 verapamil hcl ..................................................... 3 verapamil hcl ER ............................................... 3 VERELAN ........................................................... 3 VERELAN PM ..................................................... 3 VESANOID ....................................................... 11 VESICARE........................................................ 13 VESTURA ........................................................... 4 VFEND ............................................................... 9 VIAGRA .............................................................. 6 VIBRAMYCIN ..................................................... 9 VIBRAMYCIN SYRUP ........................................ 9 VIBRA-TABS ...................................................... 9 VICODIN ........................................................... 12 VICODIN ES ..................................................... 12 VICODIN HP ..................................................... 12 VICON FORTE ................................................. 14 VICTOZA ............................................................ 5 VIDEX ................................................................. 9 VIDEX EC ........................................................... 9 VIDEX SOLUTION .............................................. 9 VIGAMOX ........................................................... 7 VIIBRYD ............................................................. 1 VIMPAT ............................................................ 13 VIMPAT ORAL SOLUTION ............................... 13 VINATE GT ....................................................... 14 VINATE ULTRA ................................................ 14 VIRACEPT .......................................................... 9 VIRAMUNE ......................................................... 9 VIRAMUNE XR ................................................... 9 VIRAZOLE .......................................................... 9 VIREAD .............................................................. 9 VIROPTIC ........................................................... 7 VISKEN .............................................................. 3 VISTARIL ............................................................ 1 VISTOGARD ..................................................... 11 VIVELLE-DOT .................................................... 8 VOLTAREN .................................................. 7, 10 VOLTAREN GEL ................................................ 5 VOLTAREN-XR ................................................ 10 voriconazole ...................................................... 9 vorinostat .......................................................... 11 VOSOL ............................................................... 6 VOSOL HC ......................................................... 6 VOTRIENT........................................................ 11



VRAYLAR ........................................................... 2 vridine triacetate ............................................... 11 VYVANSE ........................................................... 2 warfarin sodium ................................................ 7 WELCHOL .......................................................... 3 WELCHOL POWDER PACKETS ....................... 3 WELLBUTRIN ..................................................... 1 WELLBUTRIN SR ............................................... 1 WELLBUTRIN XL ............................................... 1 WESTCORT ....................................................... 5 WESTHROID ...................................................... 7 XALATAN ........................................................... 7 XALKORI .......................................................... 11 XANAX ............................................................... 2 XARELTO ........................................................... 7 XELJANZ .......................................................... 11 XELJANZ XR .................................................... 11 XELODA ........................................................... 11 XENAZINE ........................................................ 11 XENAZINE ........................................................ 11 XERMELO ........................................................ 10 XIFAXAN 550MG ................................................ 9 XIIDRA ................................................................ 7 XODOL 10-300 ................................................. 12 XTANDI ............................................................ 11 XURIDEN ......................................................... 12 XYLOCAINE ..................................................... 10 XYZAL TABS ...................................................... 1 YASMIN 28 ......................................................... 4

YAZ .................................................................... 4 YODOXIN ........................................................... 9 zaleplon ............................................................. 2 ZANAFLEX ....................................................... 13 ZANTAC ........................................................... 13 ZARAH ............................................................... 4 ZARONTIN ....................................................... 13 ZAROXOLYN ...................................................... 3 ZEBETA .............................................................. 3 ZELBORAF ....................................................... 11 ZEMPLAR ........................................................... 6 ZENATANE......................................................... 4 ZENPEP ........................................................... 13 ZENZEDI ............................................................ 2 ZERIT ................................................................. 9 ZESTORETIC ..................................................... 2 ZESTRIL ............................................................. 3 ZETIA ................................................................. 4 ZIAC ................................................................... 3 ZIAGEN .............................................................. 9 ZIANA ................................................................. 4 zidovudine ......................................................... 9 ziprasidone hcl .................................................. 2 ZIRGAN .............................................................. 7 ZITHROMAX ....................................................... 8 ZITHROMAX TRI-PAK ........................................ 8 ZMAX .................................................................. 8 ZMAX PEDIATRIC .............................................. 8 ZOCOR ............................................................... 3

ZOFRAN ............................................................. 1 ZOFRAN ODT .................................................... 1 ZOFRAN SOLUTION .......................................... 1 ZOLINZA .......................................................... 11 zolmitriptan ..................................................... 12 ZOLOFT ............................................................. 1 zolpidem tartrate ............................................... 2 ZOMIG .............................................................. 12 ZOMIG ZMT ...................................................... 12 ZONEGRAN ..................................................... 13 zonisamide ...................................................... 13 ZORTRESS ........................................................ 8 ZOVIRAX ............................................................ 9 ZOVIRAX CREAM .............................................. 5 ZOVIRAX OINTMENT ........................................ 5 ZUBSOLV ......................................................... 12 Zurampic ........................................................... 18 ZURAMPIC ......................................................... 7 ZYDELIG .......................................................... 11 ZYKADIA .......................................................... 11 ZYLET ................................................................ 7 ZYLOPRIM ......................................................... 7 ZYMAXID ............................................................ 7 ZYPREXA ........................................................... 2 ZYPREXA ZYDIS ............................................... 2 ZYRTEC (OTC) .................................................. 1 ZYRTEC-D (OTC) ............................................... 1 ZYTIGA ............................................................. 11 ZYVOX ............................................................... 8

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37010 MedPerform Low Formulary July 2017 FINAL · 37010 MedPerform Low Formulary – July 2017 iii Depending upon a member’s specific benefit parameters, the following topics may